Gastric Cancer (2012) 15:396–404 DOI 10.1007/s10120-011-0129-y ORIGINAL ARTICLE Irregular bowel movement in gastrectomized subjects: bowel habits, stool characteristics, fecal flora, and metabolites Teruaki Aoki • Ichiro Yamaji • Tsuyoshi Hisamoto • Masanori Sato • Tomoko Matsuda Received: 13 May 2011 / Accepted: 3 December 2011 / Published online: 27 January 2012 Ó The International Gastric Cancer Association and The Japanese Gastric Cancer Association 2012 Abstract totally gastrectomized than in the partially gastrectomized Background We conducted a survey regarding irregular patients. bowel movement in gastrectomized patients. Their defe- Conclusions Many gastrectomized patients with irregular cation frequency, intestinal microflora, and intestinal bowel movements exhibited significant changes showing environment were studied and compared with those of impaired intestinal microflora and metabolite levels. healthy controls. Methods As a first step, a questionnaire survey on bowel Keywords Gastrectomized subjects Á Bowel movement Á movement, involving 769 patients and 312 healthy controls Stool characteristics Á Fecal flora Á Metabolites (total: 1,081 subjects), was carried out. As a second step, the defecation frequency (scoring of the survey results conducted to evaluate the state of constipation/diarrhea), Introduction intestinal microflora, and intestinal environment were evaluated in 190 gastrectomized patients with irregular Advances in surgical procedures have improved the prog- bowel movement and 31 controls identified in the first nostic results of gastric cancer treatment [1]. However, survey. very few effective strategies have been established to Results First step: Of the 769 patients, 58% complained control postgastrectomy sequelae. An increasing number of of irregular bowel movements (constipation, diarrhea, or patients suffer from sequelae: (1) malnutrition related to a their alternate occurrence), and their frequency of com- decrease in gastric hydrochloric acid/digestive enzyme plaints was significantly higher (p \ 0.01) than that in the secretion and digestive hypofunction, (2) vagotomy-related healthy controls (33%). Second step: The levels of the most reduction of digestive tract movement, (3) dumping syn- predominant obligate anaerobe and harmful bacteria in the drome, (4) reflux esophagitis, (5) iron-deficiency anemia, feces were lower and higher, respectively, the fecal pH was and (6) bone disorders related to calcium malabsorption lower, the fecal water content was lower, and the level of [2–6]. As these disorders further reduce the digestive tract putrefactive metabolites in the feces was higher in the function, approximately 50% of patients who have under- gastrectomized patients than in the healthy controls. The gone gastrectomy complain of irregular bowel movements, intestinal flora and environment were more disrupted in the including diarrhea and constipation, as postoperative sequelae (unpublished data of survey of members of the ALPHA CLUB [Postgastrectomy Patients’ Association, http://alpha-club.jp/]). No study has investigated the defe- T. Aoki (&) The Jikei University School of Medicine, #303/6-13-7 cation frequency or intestinal microflora/environment in a Honkomagome, Bunkyo-Ku, Tokyo 113-0021, Japan large number of patients who have undergone gastrectomy. e-mail: [email protected] To improve bowel movements, patients with irregular bowel movements after gastrectomy are advised to con- T. Aoki Á I. Yamaji Á T. Hisamoto Á M. Sato Á T. Matsuda Post-gastrectomy Patients’ Association ‘‘ALPHA CLUB’’, sume food containing a large amount of dietary fiber and Tokyo, Japan fermented food such as yogurt. 123 Irregular bowel movement in gastrectomized subjects 397 We conducted a questionnaire survey regarding the Examination methods defecation frequency in members of the ALPHA CLUB to obtain findings that would be useful for the prevention/ Survey by diary treatment of irregular bowel movements in gastrectomized patients. Subsequently, we selected patients with abnor- Survey on bowel movement A questionnaire survey was malities in defecation and analyzed their intestinalicroflora/ carried out to investigate the defecation frequency, stool environment. features, presence or absence of current consultations at an outpatient clinic/treatment, drug therapy, frequency of yogurt/lactic acid bacteria-beverage ingestion, and postin- Subjects, materials, and methods gestion bowel condition. (A questionnaire was sent to members of the ALPHA CLUB by mail to request them to Subjects and study schedule respond voluntarily and cooperate with a subsequent survey.) Survey on bowel movement Survey on irregular bowel movement The subjects recor- ded a diary regarding the following issue by the 24-h remem- A questionnaire survey regarding defecation frequency was bering method every day during the 2-week study period: carried out involving members of the ALPHA CLUB (Post- gastrectomy Patients’ Association, http://alpha-club.jp/) Q1 Bowel movement state (1. normal, 2. constipation, (1,060 gastrectomized subjects, age 35–79 years) and their and 3. diarrhea) families (spouses who served as controls). Questionnaire Q2 Defecation frequency sheets were collected from 782 gastrectomized subjects Q3 Stool features (several options can be chosen. 1. (collection rate 74%) and 404 controls (38%, subjects’ fami- round/solid, 2. solid, 3. banana-shaped, 4. semi-paste, 5. lies without gastrectomy). However, responses from 769 muddy, and 6. watery) gastrectomized subjects and 312 controls (total: 1,081 sub- Q4 Condition (one option only, 1. very good, 2. good, 3. jects) were analyzed upon the exclusion of those who had had usual, 4. bad, and 5. very bad) proximal gastrectomy and 13 gastrectomized subjects Q5 Drug name (you should write it only when taking a (2 actually without gastrectomy, 2 who died, and 9 who did not drug.) respond to any questions) and 92 controls (no response to Q6 Others (matters regarding diet/exercise may be freely questions). On April 18, 2008, a questionnaire was sent to the written.) subjects by mail. On May 15, the questionnaire collection We evaluated constipation and diarrhea in the subjects was completed. via the scoring of the diary results, as described below: Survey on irregular bowel movement 1. Scoring of stool features Solid stool score: [(Number of subjects selecting From among the 1,081 participants in the above survey, the ‘‘round/solid’’ 9 2) ? (Number of subjects selecting subjects in this survey were 201 gastrectomized patients ‘‘solid’’ 9 1)]/defecation frequency and 33 controls (total 234) from whom informed consent Loose stool score: [(Number of subjects selecting regarding participation was obtained. Prior to this study, ‘‘watery’’ 9 2) ? (Number of subjects selecting the study contents and methods were sufficiently explained ‘‘muddy’’ 9 1)]/defecation frequency to the subjects, and written informed consent was obtained 2. Scoring of the defecation frequency according to the Helsinki Declaration (adopted in 1964, Low frequency score: When the defecation frequency revised in 1975, 1983, 1989, 1996, and 2000). Entry cri- during 14 days was less than 14, differences from 14 teria included the absence of purgatives/antidiarrheal were regarded as the score. agents taken routinely. Of the 234 subjects, 190 gastrec- High frequency score: When the defecation frequency tomized patients (121 males, 69 females, mean age during 14 days exceeded 14, differences from 14 were 65 ± 10 years) and 31 controls (14 males, 17 females, regarded as the score. mean age 62 ± 8 years) (total 221) were analyzed, 3. Scoring of bowel movement excluding 6 who dropped out during the survey period, 1 in Constipation score: Solid stool score 9 10 ? low whom stool collection was impossible, 1 control with a frequency score ? number of answers on ‘‘constipa- history of gastrectomy, and 5 who took antimicrobial tion’’ during 14 days agents during the survey period. Diarrhea score: Loose stool score 9 10 ? high fre- This survey was conducted from June 19 until July 3, quency score ? number of answers on ‘‘diarrhea’’ 2008, and from June 26 until July 10, 2008. during 14 days 123 398 T. Aoki et al. A decrease in these scores reflects the normalization of 4. Total bacterial counts defecation or relief of constipation/diarrhea. We estab- The total number of bacteria was determined by lished these scores as indices of constipation/diarrhea. smearing a dilution of a formalin-fixed stool sample over a glass slide, staining bacteria with DAPI, detecting stained Stool test bacteria under a fluorescence microscope, and counting them using image-analysis software [9]. Sample collection and transport For a stool test, a stool sample was collected once during the final 3 days in week Measurement of the fecal concentrations of organic 2 of the survey on irregular bowel movement. The sample acids A portion of the homogenized stool was isolated, was divided into two parts, with one part placed in a tube weighed, mixed with 0.15 M perchloric acid in a fourfold (for microflora analysis) containing 2 ml of RNAlater volume, and reacted at 4°C for 12 h. Next, the mixture was (Ambion, Austin, TX, USA) and the other part placed in a centrifuged at 4°C and 20,4009g for 10 min, and the super- blank tube (for organic acid analysis, water content/pH natant was filtered with a 0.45-lm membrane filter (Millipore measurement, and determination of putrefactive metabolite Japan, Tokyo), and then sterilized. The concentrations of levels); the tubes were transported in