Gastrointestinal Nutrient Transit and Enteroendocrine Function After Upper Gastrointestinal Surgery

Study Overview
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Brief Summary
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The incidence of oesophagogastric cancer has increased by 400% since the 1970s in Ireland and the United Kingdom. In addition, refinement of perioperative management and the now widespread use of multimodal protocols for patients with locally advanced disease have significantly improved outcomes for patients with oesophagogastric cancer treatable with curative intent. Despite significant advances in chemoradiotherapy, surgical resection remains the primary curative option. Unintentional weight loss and nutritional complications represent serious concerns for patients after radical resection, even among those who remain free from recurrent disease in the long-term. A study from the Swedish Esophageal and Cardia Cancer Registry reported a mean three year weight loss of 10.8% among disease-free patients, with 33.8% of this cohort demonstrating malnutrition at three years post-oesophagectomy. Mechanisms contributing to weight loss for disease-free patients after upper gastrointestinal surgery are poorly understood, however an association between increasing magnitude of weight loss and the presence of increased satiety is described. Our recent studies at SJH have demonstrated four fold elevated postprandial satiety gut hormone concentrations after oesophagectomy, compared with baseline preoperative values. Postprandial gut hormone levels correlate significantly with postprandial symptoms and altered appetite at 3 months postoperatively, and with body weight loss at 2 years postoperatively. However, the mechanism leading to exaggerated postprandial gut hormone production after upper gastrointestinal surgery is poorly understood, limiting targeted therapeutic options. In this study, we aim to characterise the role of altered nutrient transit and enteroendocrine cell function in the pathophysiology of excessive post-prandial gut hormone responses after upper gastrointestinal surgery. To do this, we will measure the gut hormone response to a standardised 400 kcal meal, as per previous studies, while concurrently assessing gastrointestinal transit time, and enteroendocrine cell morphology and function. In this way, we will determine whether the magnitude of the postprandial gut hormone response correlates with the rate of nutrient transit into the enteroendocrine L-cell rich small intestine, and whether enteroendocrine cell adaptation occurs after oesophagectomy. Furthermore, we have previously observed that gut hormone suppression using octreotide is associated with increased ad libitum among subjects after upper gastrointestinal cancer surgery (Elliott JA et al, Annals of Surgery, 2015). The mechanism of action of octreotide may relate to SSTR-5-mediated negative feedback to the enteroendocrine L-cell, but this medication may additionally reduce enteroendocrine L-cell responses through its inhibitory effect on gastrointestinal motility - reducing the rapidity with which nutrients are delivered to the small intestine - and small intestinal nutrient sensing via inhibition of the Na+-dependent glucose transporter SGLT-18-10. Through conduction of this double-blind, randomised, placebo-controlled crossover study, we aim to establish the mechanism of action of octreotide-mediated increased food intake in patients after gastrointestinal surgery. This may inform the design of future targeted interventions for this patient group.

Official Title
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Gastrointestinal Nutrient Transit and Enteroendocrine Function After Upper Gastrointestinal Surgery

Conditions
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Surgery, Esophageal Cancer, Nutrition Disorders, Appetite Disorders, Dumping Syndrome, Delayed Gastric Emptying

Intervention / Treatment
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* Drug: Octreotide Acetate
* Drug: Saline Solution
* Drug: Paracetamol
* Drug: Sulfasalazine
* Diagnostic Test: Duodenal biopsy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient group: 1. History of upper gastrointestinal surgery at least 9 months previously Control group: 1. Patients with suspected or confirmed non-dysplastic Barrett's oesophagus or reflux who are age, weight and gender matched to the patient cohort Exclusion Criteria: Pregnancy, breastfeeding Recurrent disease after surgery Other active malignancy Significant psychiatric disorder or cognitive decline or communication impairment limiting capacity to provide informed consent Other disease or medication which may impact gut hormone physiology Previous upper gastrointestinal resection Certain allergies or dietary intolerances Anticoagulants Patients with contraindications to the study medications (as per www.medicines.ie) will not be automatically excluded, but will be invited to participate in an attenuated protocol where that agent is not given. It is not anticipated that this will be a frequent occurrence, however this strategy will minimise unnecessary participant exclusion.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Upper Gastrointestinal Surgery - Transit<br> | Drug: Octreotide Acetate<br>* 50mcg octreotide acetate by subcutaneous injection 10 minutes prior to a 400kcal mixed meal challenge<br>Drug: Saline Solution<br>* Equivalent volume of 0.9% saline by subcutaneous injection 10 minutes prior to a 400kcal mixed meal challenge<br>Drug: Paracetamol<br>* Paracetamol 1g by mouth consumed with a 400kcal mixed meal challenge<br>Drug: Sulfasalazine<br>* 1g sulfasalazine by mouth consumed with a 400kcal mixed meal challenge<br>|
| Control - Transit<br> | Drug: Octreotide Acetate<br>* 50mcg octreotide acetate by subcutaneous injection 10 minutes prior to a 400kcal mixed meal challenge<br>Drug: Saline Solution<br>* Equivalent volume of 0.9% saline by subcutaneous injection 10 minutes prior to a 400kcal mixed meal challenge<br>Drug: Paracetamol<br>* Paracetamol 1g by mouth consumed with a 400kcal mixed meal challenge<br>Drug: Sulfasalazine<br>* 1g sulfasalazine by mouth consumed with a 400kcal mixed meal challenge<br>|
| Upper Gastrointestinal Surgery - Gut Function<br> | Diagnostic Test: Duodenal biopsy<br>* Biopsy from the second part of the duodenum taken at routine endoscopic surveillance, undertaken for another clinical indication.<br>|
| Control - Gut Function<br> | Diagnostic Test: Duodenal biopsy<br>* Biopsy from the second part of the duodenum taken at routine endoscopic surveillance, undertaken for another clinical indication.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Area under the curve for paracetamol at 30 minutes after a 400kcal mixed meal stimulus |  | 30 minutes post meal | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Peak paracetamol level |  | Within 300 minutes post meal | 
| GLP-1 area under the curve over 300 minutes after a 400kcal mixed meal stimulus |  | Within 300 minutes post meal | 
| Glucose area under the curve over 300 minutes after a 400kcal mixed meal stimulus |  | Within 300 minutes post meal | 
| Insulin area under the curve over 300 minutes after a 400kcal mixed meal stimulus |  | Within 300 minutes post meal | 
| Visual analogue scales |  | Within 300 minutes post meal | 
| EORTC health related quality of life |  | At one year post surgery, on the day of assessment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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GLP-1, Gut hormones, Enteroendocrine L-cell, Early satiety, Dumping syndrome, Gastrointestinal transit, Insulin, Octreotide, Somatostatin, Esophagectomy