A Safe and Noninvasive Test for Vagal Integrity Revisited

Balaji, Nagammapudur S.; Crookes, Peter F.; Banki, Farzaneh; Hagen, Jeffrey A.; Ardill, Joy; DeMeester, Tom R.

doi:10.1001/archsurg.137.8.954

Cited by 32 publications

(24 citation statements)

References 15 publications

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“…One day after surgery, PP levels decreased to 16 (13)(14)(15)(16)(17)(18)(19) pmol/l. On day 2, serum PP was 22 (19)(20)(21)(22)(23)(24)(25)(26) pmol/l, already similar to preoperative levels ( Figure 2).…”

Section: Resultsmentioning

confidence: 96%

“…7 Pancreatic polypeptide (PP) is released from islet F-cells under cholinergic control, as evidenced by a blunted response to a meal during vagal blockade with atropine, [8][9][10][11] or following truncal vagotomy. 12,13 Increases in PP levels mediated by signals through the vagal nerve, have been used as a measure of vagal efferent function. [14][15][16] The functionality of the mucosa in the excluded stomach is difficult to examine due to its inaccessibility.…”

Section: Introductionmentioning

confidence: 99%

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Early Changes in Ghrelin following Roux-en-Y Gastric Bypass: Influence of Vagal Nerve Functionality?

et al. 2007

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Section: Resultsmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

Early Changes in Ghrelin following Roux-en-Y Gastric Bypass: Influence of Vagal Nerve Functionality?

et al. 2007

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“…There was therefore a discrepancy between the test results, gastric emptying, and the mild symptoms, which questions whether a total vagotomy was in fact done, or that the PP test is not as reliable as we would wish. Even after a total vagotomy following esophagectomy, 8% of patients are reported to have a significant rise of PP levels after sham feeding, suggesting intact vagal nerves [5]. The PP test may therefore not be entirely predictable of total vagotomy.…”

Section: Commentmentioning

confidence: 99%

“…Historically, vagal function has been assessed by gastric acid secretion stimulated by pentagastrin and histamine, a high gastric pH, increased serum gastrin concentrations (with a normal secretin test), atrophic gastritis, or by spraying Congo red onto the gastric mucosa [4].The polypeptide response to insulin hypoglycemia, used in this study, has been used in previous studies to assess vagal nerve integrity [5,6]. Insulin-induced hypoglycemia has been abandoned in the United States because of its serious risk of cardiac or cerebral insults, and sham feeding is used as an alternative.…”

Section: Commentmentioning

confidence: 99%

Gastric emptying and vagus nerve function after laparoscopic partial fundoplication

Bremner

2005

Eur Surg

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The aim of this study was to assess the impact of inadvertent vagotomy during laparoscopic fundoplication on symptoms and gastric function.This was a prospective study of vagal integrity using pancreatic polypeptide (PP) response to insulin hypoglycemia and the effect of denervation on gastric emptying.Four of 41 patients studied 3 to 6 months after surgery had a polypeptide response suggesting vagal denervation. Gastric emptying in these patients was not influenced by the alleged denervation. Furthermore, there was no correlation between symptoms and gastric emptying data. The authors conclude that vagus nerve denervation does not adversely affect the success of antireflux surgery. CommentThis was a well constructed study, and investigations were completed in all patients. It is the first study to assess the effect of laparoscopic antireflux surgery on gastric emptying in relation to vagus nerve function.Laparoscopic antireflux surgery gives excellent control of reflux symptoms, but in many patients new symptoms of diarrhea, epigastric discomfort, fullness, early satiety, and gas bloat may be present.In an extensive review by Beldi et al. of postoperative gastrointestinal symptoms after open or laparoscopic fundoplication, 12-88% of patients complained of flatulence, 17-100% of early satiety and fullness, and 15-56% of meteorism [1]. In an unpublished review of several hundred patients from our institution, 51% complained of increased abdominal cramping and bloating which was severe in only 6%. With time, these symptoms improved in 38% and resolved in 14%. Despite these symptoms, 95% were satisfied with the results of surgery.The altered physiology responsible for these symptoms has not been well studied. Barostat studies, previously reported from the team at Leiden University, have demonstrated an impairment of postprandial relaxation of the proximal stomach associated with sensations of fullness and a shorter duration of the lag phase of gastric emptying [2]. Abdominal discomfort after fundoplication could therefore also be related to an increase in the rate of gastric emptying following the operation. Generally, delayed gastric emptying is normalized after fundoplication, as was reported by our group in 1989 [3], and again in the study under discussion. This is regarded as a beneficial effect in patients with initial delayed gastric emptying, and as the authors point out, delayed gastric emptying is not a contraindication to fundoplication. We have not addressed the possibility that fundoplication may exacerbate an already increased rate of emptying.In patients with these persistent symptoms after surgery, the possibility of inadvertent vagotomy during surgery has also to be considered, and the authors address this possibility. Proof of the vagotomy following surgery has always been difficult to establish, and the effect on gastric function is not well documented.Historically, vagal function has been assessed by gastric acid secretion stimulated by pentagastrin and histamine, a high gastric pH, increased seru...

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“…The effects of these drugs, however, are unpredictable. One possible explanation for this lack of sustained response to treatment is that gastroparesis may be originally associated with progressive autonomic neuropathy [5,6] . Ghrelin, a 28-amino acid peptide with an octanoyl moiety at Ser Abstract AIM: To investigate the potential therapeutic significance of ghrelin and growth hormone releasing peptide 6 (GHRP-6) in diabetic mice with gastric motility disorders.…”

mentioning

confidence: 99%

Gastric motor effects of ghrelin and growth hormone releasing peptide 6 in diabetic mice with gastroparesis

Qiu¹,

Wang²,

Wang³

et al. 2008

WJG

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strips taken from diabetic mice. RT-PCR confirmed the presence of GHS-R mRNA in the strip preparations. CONCLUSION:Ghrelin and GHRP-6 increase gastric emptying in diabetic mice with gastroparesis, perhaps by activating peripheral cholinergic pathways in the enteric nervous system. © 2008 WJG . All rights reserved.Key words: Gastric emptying; Ghrelin; Growth hormone releasing peptide 6; Growth hormone secretagogue receptor; Diabetic mice INTRODUCTIONDelayed gastric emptying occurs in more than 50% of patients with chronic diabetes mellitus (DM) and is always associated with impaired quality of life and diabetic control. While this delay is not always clinically apparent, the range of gastrointestinal symptoms may include nausea, vomiting, regurgitation, fullness, and bloating [1] . Diabetic patients with poor gastric emptying have a number of possible metabolic consequences, including poor glycemic control, increased risk of postprandial hypoglycemia and variable drug absorption. At its worst, gastroparesis can lead to intractable vomiting and an inability to feed, and carries a poor prognosis [2] . Present management of diabetic gastroparesis involves empirical use of prokinetic drugs such as domperidone, metoclopramide, cisapride [2,3] and erythromycin [4] . The effects of these drugs, however, are unpredictable. One possible explanation for this lack of sustained response to treatment is that gastroparesis may be originally associated with progressive autonomic neuropathy [5,6] . Ghrelin, a 28-amino acid peptide with an octanoyl moiety at Ser Abstract AIM: To investigate the potential therapeutic significance of ghrelin and growth hormone releasing peptide 6 (GHRP-6) in diabetic mice with gastric motility disorders. METHODS:A diabetic mouse model was established by intraperitoneal (ip ) injection of alloxan. Diabetic mice were injected ip with ghrelin or GHRP-6 (20-200 μg/kg), and the effects on gastric emptying were measured after intragastric application of phenol red. The effect of atropine, N G -nitro-L-arginine methyl ester hydrochloride (L-N AME) or D -Lys 3 -GHRP-6 (a growth hormone secretagogue receptor (GHS-R) antagonist) on the gastroprokinetic effect of ghrelin or GHRP-6 (100 μg/kg) was also investigated. The effects of ghrelin or GHRP-6 (0.01-10 μmol/L) on spontaneous or carbachol-induced contractile amplitude were also investigated in vitro , in gastric fundic circular strips taken from diabetic mice. The presence of growth hormone secretagogue receptor 1a transcripts in the fundic strips of diabetic mice was detected by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS:We established a diabetic mouse model with delayed gastric emptying. Ghrelin and GHRP-6 accelerated gastric emptying in diabetic mice with gastroparesis. In the presence of atropine or L-NAME, which delayed gastric emptying, ghrelin and GHRP-6 (100 μg/kg) failed to accelerate gastric emptying. D-Lys 3 -GHRP-6 also delayed gastric emptying induced by the GHS-R agonist. Ghrelin and GHRP-6 increased the carbachol-indu...

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A Safe and Noninvasive Test for Vagal Integrity Revisited

Cited by 32 publications

References 15 publications

Early Changes in Ghrelin following Roux-en-Y Gastric Bypass: Influence of Vagal Nerve Functionality?

Early Changes in Ghrelin following Roux-en-Y Gastric Bypass: Influence of Vagal Nerve Functionality?

Gastric emptying and vagus nerve function after laparoscopic partial fundoplication

Gastric motor effects of ghrelin and growth hormone releasing peptide 6 in diabetic mice with gastroparesis

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