Negative Feedback Mechanism of Entero-gastric Inhibitory in Delayed Gastric Emptying Following Surgery for Stomach Cancer

Delayed gastric emptying (DGE) is a common complication following upper gastrointestinal surgery, especially following distal gastrectomy and partial pancreaticoduodenectomy (Whipple procedure). Its underlying mechanism remains unclear and needs to be elucidated. Through negative feedback mechanisms, duodenal distension inhibits gastric emptying. In our experience in performing a gastrojejunostomy, we speculate that this mechanism may still exist in the proximal jejunum and is activated by jejunal distension or stretching. There are many surgical factors leading to this mechanism activation. When a jejunal anastomosis is created by a relative large caliber of a circular stapling device, the mucosa may suffer from a circumferential scratch or bruising injury resulting in local inflammation. Afferent loop twisting may also lead to distal duodenum and/or jejunal distension. In addition, a mild/slight tension may exist on the mesenteric side of the gastrojejuostomy, especially when the antecolic route for reconstruction of the gastrojejunostomy has been performed. The inflammatory mucosa may keep the jejunum circumferentially distended, the bowel twist might compromise the lumen patency, and tension on gastrojejuostomy would stretch the jejunal wall. Any of these factors might contribute to the mechanisms of DGE by the negative feedback mechanisms.