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Introduction Laparoscopic sleeve gastrectomy is one of the most common techniques in bariatric surgery, but there is no consensus on the optimal distance from the pylorus to start the gastric transection. The aim of this study is to determine the differences in gastric emptying, gastric distension and metabolic response between two starting distances. Material and Methods This is a prospective randomised study of 60 patients (30 patients with the section at 3 cm and 30 patients at 8 cm from the pylorus). We calculate at 6 and 12 months from surgery gastric emptying by scintigraphy (T1/2 min), gastric volume by CT scan (cc) and metabolic response by blood sample analysis (glucose, HbA1c, insulin, HOMA-IR, GLP-1, GIP and C-peptide). Results Gastric emptying increases the speed significantly in both groups but is greater in the 3-cm group ( p  < 0.05). Dividing groups into type 2 diabetic patients and non-diabetic patients, the speed in non-diabetic patients is significantly higher for the 3-cm group. Residual volume increases significantly in both groups, and there are no differences between them. One year after surgery, there are significant improvements in the hyperinsulinaemia in the patients of the 3-cm group with respect to the 8-cm group, but only in diabetic patients. No differences between groups are found regarding changes in GLP-1 or GIP. Conclusions Gastric emptying is faster in patients with antrum resection. The distance does not influence the gastric emptying of diabetic patients. Other mechanisms may explain metabolic response besides GLP-1 and its association with improvements in diabetes via gastric emptying.

Background The randomized controlled PROPP trial (DKRS00004191) showed that pylorus-resecting pancreatoduodenectomy (PR) is not superior to the pylorus-preserving procedure (PP) in terms of perioperative outcome, specifically in reduction of delayed gastric emptying. Non-superiority of PR was also confirmed in a recent meta-analysis of randomized controlled trials. However, long-term data on morbidity and quality of life after PP compared to PR are sparse. The aim of this study was to investigate long-term outcomes of patients included in the PROPP trial. Methods Between February 2013 and June 2016, a total of 188 patients underwent PD and were intraoperatively randomized to either preservation or resection of the pylorus (95 vs. 93 patients). For long-term follow-up, morbidity and quality of life (EORTC QLQ-C30/PAN26) were monitored until January 1, 2018. Statistical analysis was performed on an intention-to-treat basis. Results The mean duration of follow-up was 34.3 (± 11.3) months. Sixty-three of the 188 patients had died (PP n  = 33, PR n  = 30), 29 patients were lost to follow-up (PP n  = 17, PR n  = 12), and the remaining 96 patients were included in long-term follow-up (PP n  = 45, PR n  = 51). There was no difference between PP and PR patients regarding endocrine and exocrine pancreatic function, receipt of adjuvant/palliative chemotherapy, cancer recurrence, and other relevant characteristics. Late cholangitis occurred significantly more often in patients following pylorus resection ( P  = 0.042). Reoperations, readmissions to hospital, and quality of life scores except pain were comparable between the two study groups. Conclusions Similar to short-term results, long-term follow-up showed no significant differences between pylorus resection compared to pylorus preservation.

PurposePylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques.MethodsThis pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status.ResultsA total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35–65%) in the study group and 62% (24/39, 95% CI: 46–75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status.ConclusionDGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD.Trial registrationClinicalTrials.gov Identifier: NCT03984734.

Introduction Delayed gastric emptying (DGE) due to pyloric dysfunction remains a common postoperative complication after esophagectomy for cancer and can lead to severe secondary complications. As shown in a retrospective study, prophylactic EPBD performed 1 day before surgery can reduce the rate of postoperative DGE by reducing pyloric resistance. The objective of this study is to analyze the effect of prophylactic EPBD on postoperative DGE rates in patients receiving minimally invasive esophagectomy for cancer by gastric pull-up. Methods This study is designed as a multicenter randomized controlled trial (RCT) including patients with esophageal cancer or cancer of the gastroesophageal junction (adenocarcinoma and squamous cell carcinoma, with or without neoadjuvant treatment) scheduled for minimally invasive esophagectomy with gastric pull-up. After randomization, patients will either receive preoperative EPBD or a sham intervention in the routine preoperative endoscopy performed 1 day before surgery. The primary endpoint of this study will be rates of DGE, particularly those resulting from pyloric dysfunction, requiring intervention. Secondary outcomes will be major and minor postoperative complication rates, in-hospital mortality, adverse events during gastroscopy, length of ICU and hospital stay as well as postoperative pain and quality of life. In order to detect a difference between both groups at a two-sided 5% significance level, to achieve a power of 0.8 with a calculated dropout rate of approximately 20%, a sample size of 118 patients with 59 patients in every study arm will be needed. Discussion The presented PROPPER trial is the first multicenter RCT that will provide evidence regarding the efficacy of preoperative EPBD in reducing DGE after minimally invasive esophagectomy for cancer. Trial registration This trial was registered in the German Clinical Trials Register (DRKS), under the identifier DRKS00034360. Registered on May 29, 2024. The WHO trial registration data set can be found here: http://drks.de/search/en/trial/DRKS00034360 .

Purpose While regarded as function-preserving gastrectomy, few prospective longitudinal clinical trials have addressed the postoperative quality of life (QOL) after pylorus-preserving gastrectomy (PPG). We prospectively compared chronological changes in postoperative body weight and the QOL between PPG and distal gastrectomy (DG) for pathological Stage I gastric cancer (GC). Methods We conducted a multi-institutional prospective study (CCOG1601) to evaluate patients who underwent DG and PPG. The QOL was examined using the European Organization for Research and Treatment of Cancer Quality of life questionnaire-C30 ( EORTC QLQ-C30) and the Post-Gastrectomy Syndrome Assessment Scale-37 (PGSAS-37). A total of 295 patients were enrolled from 15 institutions, and propensity score matching was performed to adjust for the essential variables for comparison analyses. Results After propensity score matching, 25 pairs of patients were identified. In the first postoperative month, DG achieved a superior nausea and vomiting score (EORTC QLQ-C30) and meal-related distress, indigestion, and dumping scores (PGSAS-37). No significant differences were noted between DG and PPG in the long-term QOL. Postoperative body weight loss was similar in both groups. Conclusions This prospective observational study failed to demonstrate the superiority of PPG over DG in terms of postoperative body weight changes and the QOL.

Background Pylorus-preserving partial pancreatoduodenectomy (ppPD) is a treatment for tumors of the pancreatic head. Delayed gastric emptying (DGE) is one of the most common complications following ppPD. In a retrospective analysis, intraoperative endoluminal pyloromyotomy (PM) was shown to be associated with a reduction in DGE rates. Objective The aim of this randomized controlled trial was to investigate the effect of intraoperative endoluminal PM on DGE after ppPD. Methods Patients undergoing ppPD were randomized intraoperatively to receive either PM or atraumatic stretching of the pylorus prior to creation of the duodenojejunostomy. The primary endpoint was the rate of DGE within 30 days after surgery. Results Sixty-four patients were randomly assigned to the PM group and 64 patients were assigned to the control group. There were no differences between the two groups regarding baseline characteristics. The DGE rate was 59.4% (76/126). In two patients (1.6%) DGE was not assessable. The most common DGE grade was A (51/126, 40.5%), followed by B (20/126, 15.9%) and C (5/126, 4.0%). The rate of DGE was 62.5% in the PM group versus 56.3% in the control group (odds ratio 1.41, 95% confidence interval 0.69–2.90; p  = 0.34). The complication rate did not differ between both groups ( p  = 0.79) and there were no differences in quality of life on postoperative day 30. Conclusions Intraoperative endoluminal PM did not reduce the rate or severity of DGE after ppPD compared with atraumatic stretching of the pylorus.

Clarify the long-term outcomes of laparoscopic-assisted pylorus-preserving gastrectomy (LAPPG) compared to conventional laparoscopic-assisted distal gastrectomy with billroth I anastomosis (LADGBI) for early gastric cancer(pT1N0M0). Patients with cT1N0M0 cancer located in the middle third of the stomach and not suitable for endoscopic submucosal dissection were randomized to undergo LAPPG or LADGBI. Between August 2017 and October 2019, a total 88 patients (pT1N0M0) were analyzed. The 5-year overall survival rate and disease-free survival rate were 95.5 ​% and 93.2 ​% for LAPPG and 93.2 ​% (P ​= ​0.46) and 91.0 ​% (P ​= ​0.64) for LADGBI. During postoperative 5-year follow up, LAPPG tended to present better functions and less symptoms scales than LADGBI accompanied by effective gallbladder emptying and pylorus function preserving. Surgical and oncological outcomes was comparable in pT1N0M0 patients undergoing LAPPG and LADGBI. LAPPG had advantages in long-term QOL over LADGBI in terms of C30 and STO22 questionnaire. •LAPPG was demonstrated oncologically safe compared to LADGBI.•LAPPG had advantages in long-term QOL over LADGBI in terms of C30 and STO22 questionnaire.•Delayed gastric emptying and mortality was comparable in patients undergoing LAPPG and LADGBI.

Introduction Double pylorus, or acquired gastroduodenal fistula, is a rare endoscopic finding, reported in only 0.001–0.4% of upper gastrointestinal examinations. We describe a case of acute gastrointestinal bleeding associated with a double pylorus in an elderly patient. Case presentation A 78-year-old white woman recovering from a pelvic ring fracture was admitted to a rehabilitation unit and received prophylactic dalteparin. She had no prior history of peptic ulcer disease or gastritis. After 2 weeks, she developed acute weakness, abdominal discomfort, nausea, and vomiting, accompanied by a 2.9 g/dL drop in hemoglobin. Urgent upper endoscopy revealed a double pylorus, and biopsy confirmed Helicobacter pylori infection. We reviewed published clinical reports of double pylorus. Most patients were older adults, and abdominal pain or gastrointestinal bleeding were frequent presenting symptoms. Use of nonsteroidal anti-inflammatory drugs or corticosteroids and the presence of Helicobacter pylori infection were commonly reported among described cases, although the quality and completeness of available data varied. Conclusion Double pylorus is a rare but clinically relevant condition that may first be detected when complications such as gastrointestinal bleeding occur. Reported associations with H. pylori infection and nonsteroidal anti-inflammatory drug exposure represent observational trends rather than established causal relationships, as the evidence remains heterogeneous and limited. The condition likely develops in the setting of multifactorial impairment of gastroduodenal mucosal integrity, particularly in older or medically vulnerable individuals.

Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

PurposeTo analyze how considering the structure of normotonic pylorus (NP) or hypotonic pylorus (HP) contributes to treatment success in patients administered gastric botulinum toxin A for weight loss.Materials and MethodsWe measured body mass indexes (BMIs) of the patients who applied for gastric botulinum toxin A (BTA) for weight loss, before and 6 months after the procedure. The patients’ pylori were classified as normotonic pylorus (NP) if, during endoscopy, they had a normal peristaltic motion and was closing completely, and as hypotonic pylorus if they were not closing properly or were aperistaltic. We compared the patients’ mean pre-operative and 6-month post-operative BMIs. The groups were compared using the chi-square test where a p ˂ 0.05 was considered significant.ResultsThe study included 178 patients administered gastric BTA. In the assessment made without considering the pyloric structure, the mean BMI decreased from 34.76 ± 7.65 to 33.09 ± 7.80 kg/m2, while the difference was not statistically significant (p ˂ 0.06). Conversely, in the analysis performed considering the structure of pylorus, the mean pre-operative BMI of the 45 patients with HP structure was 35.16 ± 7.07 kg/m2 which decreased to 35.11 ± 7.03 kg/m2 6 months after the procedure; hence, the difference was not statistically significant (p ˂ 0.7). The mean pre-operative BMI of the 133 patients with NP structure, 34.63 ± 7.84 kg/m2, decreased to 32.40 ± 8.05 kg/m2 6 months after the procedure and the difference was statistically significant (p ˂ 0.05)*.ConclusionWe advise to be selective in BTA administration and to administer BTA to the patients who, endoscopically, have a NP structure.