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Outcomes of Minimally Invasive Esophagectomy without Pyloroplasty: Analysis of 109 Cases
Abstract
Pyloroplasty is performed during esophagectomy to avoid delayed gastric emptying. However, studies have shown that gastric function is minimally impaired even without a pyloroplasty when a gastric tube rather than the whole stomach is used for reconstruction. The aim of this study was to evaluate outcomes of minimally invasive esophagectomy without performance of a pyloroplasty. We performed a retrospective review of 145 patients who underwent a minimally invasive esophagectomy. The 30-day mortality was 2.1 per cent with an in-hospital mortality of 3.4 per cent. Of the 140 patients with more than 90 days follow-up, 31 patients had a pyloroplasty and 109 patients did not. One (3.2%) of 31 patients with pyloroplasty versus six (5.5%) of 109 patients without pyloroplasty developed delayed gastric emptying. There was no significant difference in the leak rate between the two groups (9.7% vs. 9.6%, respectively). Total operative time was significantly shorter in the group without pyloroplasty (360 vs. 222 minutes with a pyloroplasty, P < 0.01). Patients with delayed gastric emptying responded well to endoscopic pyloric dilation or Botox injection. The routine performance of a pyloroplasty during minimally invasive esophagectomy can be safely omitted with a reduction in operative time and minimal adverse effects on postoperative gastric function.
... A total of six RCTs and seven cohort studies concerning pyloric drainage versus no drainage were included [15][16][17][18][19][20][21][22][23][24][25][26][27]. Pyloric drainage did not influence the incidence of DGE after esophagectomy (relative risk,: 0.91; 95% confidence interval, 0.57 to 1.43; Fig 3). ...
... Definitions of DGE varied across the pooled studies. In some studies, DGE was defined as symptoms of gastric stasis combined with a delay on a barium swallow or gastric conduit dilatation on radiography [23,27]. In other studies, only symptoms of gastric stasis (postprandial fullness, vomiting, regurgitation) were reported as DGE [17,18]. ...
... Two recent cohort studies demonstrated that pyloric drainage was associated with an insignificant trend for increased DGE [24,28]. In another study, gastric outlet obstruction was present in 28% of patients who underwent a pyloric drainage procedure compared with 18% of patients with no pyloric intervention (p ¼ 0.01) [23]. In addition, pyloric drainage was associated with significantly more reflux and its sequelae [22,25,27]. ...
Delayed gastric emptying is observed in 10% to 50% of patients after esophagectomy with gastric interposition. The effects of gastric interposition diameter, pyloric drainage, reconstructive route, and anastomotic site on postoperative gastric emptying were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Most studies showed superior passage of the gastric tube compared with the whole stomach. Pyloric drainage is not significantly associated with the risk of developing delayed gastric emptying after esophagectomy. For reconstructive route and anastomotic site, available evidence on delayed gastric emptying is limited. Prospectively randomized studies with standardized outcome measurements are recommended.
... 5 A detailed description of this procedure is provided in their series of publications. 10 Nguyen et al 33 recently reported a series of 140 patients who underwent MIE, of which 31 patients underwent a pyloroplasty. Of the 109 patients who did not undergo pyloroplasty, 5.5% developed delayed gastric emptying, which responded well to endoscopic dilatation or botox injection as compared with 3.2% in the pyloroplasty group. ...
... They concluded that pyloroplasty can be safely omitted from the MIE procedure. 33 A recent systematic review performed by Akkerman et al 30 concluded that the omission of pyloric drainage probably leads to a reduction of biliary reflux in the long term but, the effect on gastric emptying during the early postoperative period is controversial and is of uncertain relevance. ...
Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
... In two prospective randomized studies, pyloroplasty significantly decreased the gastric emptying times and increased the oral intake, 19,20 but another two studies reported no significant benefit from pyloroplasty. 21,22 Moreover, the long-term outcome of pyloroplasty has not been well established. Although delayed gastric emptying was not investigated in this study, we expect that pyloroplasty reduces weight loss by hastening gastric emptying. ...
... No pyroplasty-related 24 However, Nguyen et al. reported that adding pyloroplasty to minimally invasive esophagectomy is safe but increases the operation time, so can be omitted. 22 Recently, laparoscopic pyloroplasty has been reported as a safe and easy procedure that might resolve the technical difficulties and also shorten the operation time. 25 Thus, adding pyloroplasty to esophagectomy should rarely compromise the short-term outcome. ...
Weight loss after esophagectomy is common and is associated with unfavorable prognosis. However, the clinical features and surgical methods that influence postesophagectomy weight loss are not well characterized. This study aims to determine those features (especially the surgical methods) that may affect postoperative weight loss. We reviewed 221 esophageal cancer patients who had undergone esophagectomy at Kumamoto University Hospital (Kumamoto, Japan) between November 2012 and June 2015. Among these, we recruited 106 patients who had undergone transthoracic esophagectomy with gastric conduit reconstruction, had no cancer recurrence within 1 year, and no missing follow-up data. We tabulated the body weight changes and risk factors associated with weight loss exceeding 10% at 1-year postesophagectomy. The mean body weights at baseline and 1-year postsurgery were 60.3 kg (standard error (SE): 0.91) and 52.6 (SE: 0.91), respectively. One year postsurgery, the body weights had changed as follows: mean: −12.2%; median: −12.9%; standard deviation: 9.06; range: −36.1–18.56%; interquartile range: −10.5 to −14.0%. In the multivariate logistic regression analysis, the absence of pyloroplasty was the sole risk factor for more than 10% weight loss (OR: 3.22; 95% CI: 1.08–11.9; P = 0.036). Our data suggest that pyloroplasty with esophagectomy can overcome the post-surgical weight loss.
... 6 However, recent studies have challenged this decision, and it was shown that the function of the stomach is minimally impaired the formation of gastric tube used for reconstruction. 1,7 Drainage procedure such as pyloroplasty or pyloromyotomy not consistently prevent delays gastric empting. They, however, may increase postoperative complications such additional sutureline leaks, orperforation when pyloromyotomy selected. ...
... Aspiration and aspiration pneumonia are the most common and devastating early postoperative complications after esophagogastrectomy. 6,9,16 Many who prefer pyloroplasty argue that it helps gastric emptying associated with pyloric denervated and hence reduces the risk of pulmonary aspiration. 1,6,7 However, it renders the pylorus incompetent and risks life-long bile reflux after esophagogastrectomy. It can lead to long-term bile reflux, for which there is no satisfactory treatment. ...
... However, such interventions increase operative time, are related to morbidity such as bile reflux, pyloric closure site leak, and perforation due to dilatation. [4][5][6][7][8] Furthermore, prophylactic pyloric interventions will result in treating all patients, subjecting them all to the risk of the procedure, even in those that may not have a problem with DGE. ...
... Recently, intrapyloric botulinum toxin injection has gained favor in DGE management due to its reversible effect, low risk, ease of administration, and it is the least invasive approach compared to the other methods. [6][7][8][9][10][11][12][13] However, there is lack of high quality evidence as highlighted by three recent systematic reviews, which discuss the lack of standardization of diagnosis, management, and the paucity of randomized controlled trials to determine the gold standard treatment. 2,4,9 We sought to evaluate the effectiveness of intraoperative endoscopic botulinum toxin injection to the pylorus in preventing DGE after ILGO. ...
Delayed gastric emptying (DGE) is a common morbidity that affects 10%–50% of Ivor–Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0–75.0) days: 9 (7.0–75.0) in BOTOX and 10 (6.0–70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6–57) versus 14 (7–75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.
... Retention in the gastric tube is a clinically important problem after esophagectomy [1][2][3]. Gastric tube retention causes nausea and nutritional difficulties, but also poses a risk for aspiration and of pneumonia, all factors negatively affecting the patient's quality of life (QoL) [4][5][6]. Esophagectomized patients often describe symptoms that can be associated with retention, even though gastric emptying proves normal when tested [7]. ...
Scintigraphy is the gold standard for objective measurement of delayed gastric tube emptying after esophagectomy. The aim of this pilot study is to validate, by reference to scintigraphy, the paracetamol absorption test for measuring gastric tube emptying in esophagectomized patients.
The paracetamol absorption test and scintigraphy were performed simultaneously in 13 patients who had undergone an esophagectomy with gastric tube reconstruction. Emptying was calculated for both methods and compared. Post-esophagectomy symptoms and quality of life (QoL) were assessed by European Organization on Research and Treatment of Cancer questionnaires.
Mean time to 50% emptying was 17 min measured with the paracetamol absorption test and 23 min with scintigraphy. For time to 25% emptying, Bland-Altman calculation gave a bias of 1.6 min and 95% limits of agreement (LoA) of -6.3 to 9.5 min. For time to 50% emptying, there was one outlier resulting in a bias of -6.33 min and 95% LoA of -36.4 to 23.8 min. For time to 75% emptying, bias was -11.6 min and 95% LoA of -38.5 to 15.4 min. Post-esophagectomy symptoms were similar to those reported previously, and QoL was comparable to the general Swedish population.
There was reasonably close correlation between the paracetamol absorption test and scintigraphy for time to 25% and 50% emptying, except for one outlier. For time to 75% emptying the methods were in less accordance. The results indicate that the paracetamol absorption test may be a useful screening tool for identifying delayed gastric tube emptying in this patient group.
... Results of two meta-analysis studies suggest that the procedures could reduce gastric emptying time and rate of postoperative gastric outlet obstruction. [10,11] The results of a more recent meta-analysis which reviewed studies within the last decades indicated that pyloric drainage was unnecessary and could be omitted, [18] whereas another recent review study concluded that using of pyloric drainage strategies may be obsolete with the use of modern gastric tubes. [13] There were some similar regional and worldwide studies that compared some methods of pyloric drainage. ...
Background
There are controversies regarding the usefulness of the pyloric drainage methods after esophagectomy as well as differences among various pyloric drainage techniques. Therefore, we compared the outcome of pyloromyotomy, pylorus buginage, and no intervention methods on gastric emptying among patients undergone esophagectomy.
Materials and Methods
In this randomized clinical trial, patients with diagnosed esophageal cancer or any other benign lesions candidate for esophagectomy were selected. They randomized in three groups with three different approaches for gastric pull-up esophageal surgery including esophagectomy with pyloromyotomy, esophagectomy without intervention, and esophagectomy with pylorus buginage. The outcomes of procedures regarding gastric emptying time and delayed gastric emptying were compared.
Results
Thirty patients were allocated in three groups. Gastric emptying time was not significantly different in the three groups (P > 0.05). Frequency of delayed gastric emptying, complications and barium leakage were not different in three studied groups (P > 0.05).
Conclusion
Gastric emptying time and delayed gastric emptying were not different between common pyloric drainage methods after esophagectomy and esophagectomy without drainage.
... Pyloroplasty following esophagectomy appeared to reduce the incidence of gastric outlet obstruction and to accelerate gastric emptying, as well as improving gastrointestinal motility [1]. However, Nguyen et al. [10] reported that routine pyloroplasty during minimally invasive esophagectomy can be safely omitted, with a reduction in operative time and minimal adverse effects associated with postoperative gastric function. In the present study we compared the postoperative gastrointestinal motility of thoraco-laparoscopic esophagectomy with routine open 3-field esophagectomy in terms of clinical symptoms (e.g., first flatus time, first defecation time, and bowel tone recovery time) and functional index (e.g., total amount of gastric juice draining). ...
Background
The aim of this study was to investigate the surgical method, postoperative complications, and gastrointestinal motility of thoraco-laparoscopic esophagectomy in the treatment of esophageal cancer.
Material/Methods
Using random sampling method, we selected 132 esophageal cancer patients who were treated in our hospital from January 2012 to December 2014; these patients were regarded as the study group and underwent thoraco-laparoscopy 3-field surgery treatment. Another 108 esophageal cancer patients admitted to our hospital over the same period were regarded as the control group and underwent traditional open McKeown esophagectomy.
Results
The amount of blood loss and postoperative drainage of pleural fluid in the study group were significantly lower (P<0.05) and the time to removal of the chest tube and hospital stay were significantly shorter (P<0.05). The incidence of anastomotic fistula, vocal cord paralysis, chylothorax, and arrhythmia were significantly lower in the study group than in the control group (P<0.05). However, no significant differences in the incidence of pneumonia, atelectasis, or acute respiratory distress were detected (P>0.05). For postoperative gastrointestinal motility, first flatus time, first defecation time, and bowel tone recovery time after the operation, as well as the total amount of gastric juice draining, were reduced in the thoraco-laparoscopic esophagectomy group (P<0.05). The postoperative MTL and NO levels were higher but VIP level was lower in the thoraco-laparoscopic group (P<0.05).
Conclusions
Thoraco-laparoscopic esophagectomy was technically feasible and safe; it was associated with lower incidence of certain postoperative complications and had less effect on postoperative gastrointestinal motility. Skilled technique and cooperation could further shorten the operation time and might lead to better patient outcomes.
... Asocierea evacuării întârziate a grefonului gastric vagotomizat după esofagectomie cu apariţia fistulei anastomotice a determinat includerea în tehnica operatorie a piloromiotomiei extramucoasă sau a piloroplastiei Heinecke-Mikulicz pe cale laparoscopică. Piloroplastia prelungeşte durata intervenţiei chirurgicale şi are riscurile ei şi nu este indicată de rutină, de asemenea, unele studii au constatat că nu există nici o diferenţă în rezultatul funcţional pe termen lung privind evacuarea întârziată gastrică [37]. Multe centre utilizează piloroplastia chimică prin injectarea intraoperatorie a pilorului cu toxină botulinică ca profilaxie împotriva evacuării gastrice întârziate, dar efectele sunt temporare şi nu este folosită de rutină, iar unii autorii consideră că nu este necesară în esofagectomia minim invazivă [38]. ...
Breast cancer is one of the most severe health issues globally, but the therapy advancements and the constant adaptation of treatment protocols radically changed its prognoses. This article review of the literature from a surgical perspective, thus allowing for the optimum detection and placement of its role and benefits in the surgical and oncology therapeutics. The role of surgery becomes controversial, with sometimes "pretentious" techniques, hard to quantify benefits and challenges that require a thorough assessment prior to opting for surgery. Another interesting aspect is the relative lack of guidelines for such cases with an extreme lesion plurimorphism. This is the very reason for the term "advanced breast cancer" NOT covering all possible situations, leaving room for niches difficult to frame within a therapy plan.
... Pyloroplasty prolongs the duration of surgery and has its own risks and is not routinely indicated. Some studies have also found that there is no difference in the longterm functional outcome of delayed gastric evacuation (37). Many centers use chemical pyloroplasty by injecting intrapiloric botulinum toxin as prophylaxis against delayed gastric emptying, but the effects are temporary and the technique is not routinely used, and some authors find it is unnecessary in minimally invasive esophagectomy (38). ...
Abstract
The treatment of esophageal cancer has become more effective due to advances in surgical techniques, multidisciplinary approach, appropriate use of neoadjuvant therapy and perioperative care at centers of excellence in esophageal surgery. Esophagectomy is one of the most complicated and demanding procedures among all gastrointestinal surgeries with a very long learning curve in which excellence can only be achieved through improvement during all the surgical career. The results of esophagectomy are related not only to the volume of cases operated but also to the experience of surgeons in the management of postoperative complications. Initially, minimally invasive esophagectomy has encountered obstacles to implementation in several centers due to the cost and complexity of esophageal cancer treatment. Several meta-analyses and clinical trials published so far support the feasibility of the minimally invasive approach, the advantages of the post-operative period and the equivalence of oncological outcomes with the open technique, which is an important step in imposing minimally invasive techniques as a standard in the treatment of esophageal cancer. In this paper, we aim to analyze recent advances in minimally invasive esophagectomy, the evolution of endoscopic surgical techniques through our personal experience and the results of studies published in the medical literature in the last years.
https://www.ncbi.nlm.nih.gov/pubmed/29509529
... The existing literature in refer to omission of pyloric intervention at the index operation (open or even minimal invasive) is controversial. The avoidance of intraoperative drainage gained important field in the era of minimally invasive esophagectomies (2,3). Gastric motility and transit time is actually not significantly impaired, even in the absence of pyloric drainage, 1st Intensive Care Unit (ICU) of the General Hospital of Attica "KAT", Athens, Greece especially in cases of gastric tube rather than whole stomach approach for reconstruction. ...
Dear Editor, delayed gastric emptying due to bilateral vagotomy after esophagectomy, has been associated with increased aspiration rates, prolonged hospital stay and impaired quality of life. A pyloric drainage procedure in an effort to reduce its incidence, most commonly a pyloroplasty, represented for years a standard part of distal esophagectomy. This trend has been reevaluated nowadays and the question that still remains open is whether we should further keep on draining pylorus during esophagectomy or not. Surgical pyloric drainage (pyloroplasty/pyloromyotomy), although effective, is directly related to respectable complication rates, such as leakage, bile reflux, dumping sydrome or even postoperative stenosis, with potential fatal outcome. There are several proposed techniques for performing a pyloroplasty nowadays. Heineke- Mikulicz variant is the most widely practiced pyloroplasty (in contrary to Finney or Jaboulay alternatives) and is ideally performed via a 5-cm-long fullthickness antroduodenal longitudinal incision. Pyloroplasty can also be safely performed with a circular or linear stapler, while laparoscopic assisted trans-oral stapled pyloroplasty is also feasible (1).
... The abdominal phase of minimally invasive Ivor Lewis esophagectomy is performed by a standard laparoscopic approach without pyloroplasty [5]. The main portion of a gastric conduit (4 -6 cm in diameter) is created using three to four firings of a linear stapler (Ethicon Endosurgery, Cincinnati, OH). ...
We describe a pursestring stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy, in which a pursestring is hand sewn through the muscular layer of the intact esophagus by using one piece of 3-0 Prolene suture. The anvil of a circular stapler is inserted through an esophageal incision, 2 to 3 cm distal to the pursestring, and secured by the pursestring. The esophagus is transected, and the mucosa of the proximal stump is retained 5 mm longer than the adjacent muscular layer. The gastroesophageal anastomosis is completed and embedded by using the previously reserved 2 cm of mediastinal pleura.
... In a propensity matched comparison of patients with open esophagectomy that received surgical drainage against MIE without any drainage, Mehran and colleagues demonstrated no difference in reported dumping, reflux, or overall satisfaction at a median of 12-month follow-up [16]. Similarly, a series of 145 patients comparing pyloroplasty versus no drainage in MIE demonstrated that drainage could be safely omitted with minimal difference in gastric emptying and reduced operative time [19]. In the peri-operative and long-term period neither Botulinum injection nor surgical drainage has been shown to provide a definitive benefit over no drainage; as such, foregoing pyloric drainage may be a safe, reasonable option in MIE. ...
Introduction
Pyloric drainage during minimally invasive esophagectomy (MIE) may be more technically challenging than with an open approach. Alternatives to classic surgical drainage have increased in popularity; however, data are lacking to demonstrate whether one technique is superior in MIE. The purpose of this study was to compare post-operative outcomes after MIE between different pyloric drainage methods.
Methods
We performed a retrospective review of a prospectively maintained database of patients undergoing MIE at a single academic institution. Patients were divided into three groups for analysis: no drainage, intrapyloric Botulinum Toxin injection, and surgical drainage (pyloroplasty or pyloromyotomy). The primary outcome was any complication within 90 days of surgery; secondary outcomes included reported symptoms and need for pyloric dilation at 6 and 12 months post-operatively. Comparisons among groups were conducted using the Kruskal Wallis and Chi Square tests.
Results
There were 283 MIE performed between 2011 and 2017; of these, 126 (45%) had drainage (53 Botulinum injection and 73 surgical). No significant difference in the rate of post-operative complications, pneumonia, or anastomotic leak was observed between groups. At 6 and 12 months, patients that received Botulinum injection and surgical drainage had significantly more symptoms than no drainage (p < 0.0001) and higher need for pyloric dilation at 6 months (p = 0.007).
Conclusions
Pyloric drainage was not significantly associated with lower post-operative complications or long-term symptoms. While Botulinum injection appears safe post-operatively, it was associated with increased morbidity long-term. Pyloric drainage in MIE may be unnecessary.
... No patients developed port-site metastases in the TLE group. The 5-year disease-free survival was 38% in the TLE group and 36% in the OE group Minimally invasive esophagectomy for esophageal carcinoma is still a developing field [23][24][25]. Even though more than 20 years have already elapsed since the first minimally invasive esophagectomy was performed, only in the recent years this surgical procedure is gaining progressive acceptance [26][27][28][29][30]. ...
The aim of this study is to evaluate surgical results and long-term survival of combined thoracoscopic-laparoscopic esophagectomy (TLE) performed for esophageal squamous cell carcinoma. Data of 59 patients with esophageal squamous cell carcinoma, undergoing TLE from January 2007 to January 2015, were compared to a control group of 59 patients who underwent open esophagectomy (OE) during the same period. The two groups were matched in terms of age, sex, American Society of Anesthesiology (ASA) score and clinical TNM stage. Laparoscopic approach resulted in longer operating time (P=0.003) and lower blood loss (P=0.000). There was no difference in perioperative morbidity and mortality rate; TLE approach was associated with a shorter hospital stay (P=0.000). After a mean follow up of 38 months, 5-year disease free survival and 5-year overall survival were 38% and 50% for TLE group, and 36% and 45% for OE group (P>0.05). TLE for esophageal squamous cell carcinoma is feasible and safe in selected patients and can result in good surgical results, with similar outcomes in terms of long-term outcomes.
... In 2013, another meta-analysis aimed to readdress the issues, evaluating outcomes from studies performed within the last decade. 11,22,29,30 Each of the studies considered in this publication suggested that pyloric drainage was unnecessary and could be omitted. Reasons for the shift in paradigm may be related to an evolution over time with regard to the type of gastric conduit used, as it has been shown that use of whole stomach pull-ups has a greater tendency toward gastric outlet obstruction and delayed gastric emptying. ...
Controversy remains regarding the role of pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. We aimed to compare the effect of pyloric drainage strategies upon subsequent risk of complications suggestive of conduit distention, including aspiration and anastomotic leak.
A retrospective study was conducted reviewing patients undergoing esophagectomy between January 2007 and April 2012. Prospectively collected data included baseline comorbidities, operative details, hospital course, and complications. Statistical comparisons were performed using analysis of variance for continuous variables and χ(2) testing for categorical variables.
There were 361 esophagectomies performed during the study period; 68 were excluded from analysis (for prior esophagogastric surgery or benign disease or both). Among 293 esophagectomies included, emptying procedures were performed as follows: 44 (15%), no drainage procedure; 197 (67%), pyloromyotomy/pyloroplasty; 8 (3%), dilation alone; 44 (15%), dilation plus onabotulinumtoxinA. Aspiration occurred more frequently when no pyloric intervention was performed (5 of 44 [11.4%] versus 6 of 249 [2.4%], p = 0.030). The incidences of anastomotic leak (18 [6.1%]) and gastric outlet obstruction (5 [1.7%]) were statistically similar among groups. Subgroup analysis demonstrated persistence of these findings when limiting the comparison to transthoracic esophagectomies. Major complications directly related to pyloroplasty/pyloromyotomy occurred in 2 patients (0.6%), including 1 death (0.3%).
These data suggest that omission of pyloric intervention at the index operation results in more frequent aspiration events. The combination of dilation plus onabotulinumtoxinA provided for a similar complication profile compared with surgical drainage. Future prospective comparisons are needed to evaluate these short-term effects of pyloric intervention as well as long-term sequelae such as dumping syndrome and bile reflux.
... Each method has its advantages and disadvantages, so we cannot say with certainty which one is the best. However, advocates for the no-intervention strategy have been gradually reporting convincing results [40,55,56]. ...
The quality of life associated with eating is becoming an increasingly significant problem for patients who undergo esophagectomy as a result of the improved survival rate after esophageal cancer surgery. Delayed gastric emptying (DGE) is a common complication after esophagectomy. Although several strategies have been proposed for the management and prevention of DGE, no clear consensus exists. The purpose of this review is to present a brief overview of DGE and to help clinicians choose the most appropriate treatment through an analysis of DGE by cause. Furthermore, we would like to suggest some tips to prevent DGE based on our experience.
... In 2010, Nguyen et al. [39] published a retrospective study comparing PP and no PD in patients who underwent minimally invasive esophagectomy. DGE and esophagitis were more common in the no-PD group, the leakage rates were similar, and the operation time was shorter in the no-PD group. ...
Vagal damage and subsequent pyloric denervation inevitably occur during esophagectomy, potentially leading to delayed gastric emptying (DGE). The choice of an optimal pyloric procedure to overcome DGE is important, as such procedures can lead to prolonged surgery, shortening of the conduit, disruption of the blood supply, and gastric dumping/bile reflux. This study investigated various pyloric methods and analyzed comparative studies in order to determine the optimal pyloric procedure. Surgical procedures for the pylorus include pyloromyotomy, pyloroplasty, or digital fracture. Botulinum toxin injection, endoscopic balloon dilatation, and erythromycin are non-surgical procedures. The scope, technique, and effects of these procedures are changing due to advances in minimally invasive surgery and postoperative interventions. Some comparative studies have shown that pyloric procedures are helpful for DGE, while others have argued that it is difficult to reach an objective conclusion because of the variety of definitions of DGE and evaluation methods. In conclusion, recent advances in interventional technology and minimally invasive surgery have led to questions regarding the practice of pyloric procedures. However, many clinicians still perform them and they are at least somewhat effective. To provide guidance on the optimal pyloric procedure, DGE should first be defined clearly, and a large-scale study with an objective evaluation method will then be required.
... Audit data for 1220 oesophagectomies carried out in England and Wales from April 2011 to March 2012 showed that 29.7% of patients would experience a complication while 8.9% would experience serious morbidity requiring a reoperation [1]. The thirty-day mortality rate is 1.7% [13]. ...
Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty-five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non-significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.
A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy with gastric conduit reconstruction. Earlier data recommend performing a pyloric drainage procedure for all esophagectomies; however, recent studies have questioned this. A thorough literature search (January 2001-November 2011) was performed using the terms esophagectomy, pyloroplasty, pyloromyotomy, botulinum toxin, and pyloric drainage. Only studies that compared patient outcome after undergoing an esophagectomy with a pyloric drainage procedure with those undergoing an esophagectomy without a pyloric drainage procedure were selected. Only four studies, comprising 668 patients in total, were identified that compared patient outcome after undergoing an esophagectomy with or without a pyloric drainage procedure, and two additional meta-analyses were identified and selected for discussion. All studies were retrospective, and because of the heterogeneity of studies, patient demographics, reporting, and statistical analysis of patient outcome, pooling of data and meta-analysis could not be performed. Careful analysis demonstrated that pyloric drainage procedure was associated with a non-significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was determined between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity. While there are risks associated with a pyloric drainage procedure and data exist supporting its omission during an esophagectomy, no good conclusion can be drawn from the current literature. Larger multi-institutional, prospective studies are required to definitively answer this question.
Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.
Despite decreasing overall morbidity with minimally invasive esophagectomy (MIE), conduit functional outcomes related to delayed emptying remain challenging, especially in the immediate postoperative setting. Yet, this problem has not been described well in the literature. Utilizing a single institutional prospective database, 254 patients who underwent MIEs between 2012 and 2020 were identified. Gastric conduit dilation was defined as a conduit occupying >40% of the hemithorax on the postoperative chest X-ray. Sixty-seven patients (26.4%) demonstrated acute conduit dilation. There was a higher incidence of conduit dilation in the patients who underwent Ivor Lewis esophagectomy compared to those with a neck anastomosis (67.2% vs. 47.1%; P = 0.03). Patients with dilated conduits required more esophagogastroduodenoscopies (EGD) (P < 0.001), conduit-related reoperations within 180 days (P < 0.001), and 90-day readmissions (P = 0.01). Furthermore, in 37 patients (25.5%) undergoing Ivor Lewis esophagectomy, we returned to the abdomen after intrathoracic anastomosis to reduce redundant conduit and pexy the conduit to the crura. While conduit dilation rates were similar, those who had intraabdominal gastropexy required EGD significantly less and trended toward a lower incidence of conduit-related reoperations (5.6% vs. 2.7%). Multivariable analysis also demonstrated that conduit dilation was an independent predictor for delayed gastric conduit emptying symptoms, EGD within 90 days, conduit-related reoperation within 180 days, and 30-day as well as 90-day readmission. Patients undergoing MIE with acute gastric conduit dilation require more endoscopic interventions and reoperations.
Despite the scarcity of level I evidence, many strongly held opinions persist regarding best practices for the surgical management of esophageal and gastroesophageal junction tumors. The range of opinions span from a seeming nihilism, wherein the role of esophagectomy is considered to be primarily palliative, to a belief in “radical” resections, wherein an en bloc esophagectomy constitutes the major componentof a curative treatment strategy. Fortunately, some data have accrued during the past decade that can help clarify at least some of the principle areas of importance in esophageal resection. This new knowledge includes clarifi cation of the variable risks of developing nodal disease, on the basis of tumor stage, and what role the assessed risk should play in the choice of operation, the importance of operative margins, and the oncologic implications of technical complications. In addition, there is now a betterunderstanding of what is truly necessary in an esophagectomy and what is lore. Ultimately, if these principles are considered when choosing a surgical approach, some of the controversies regarding esophagectomy should be resolved.
This chapter reviews the management of patient with Barrett’s esophagus, from metaplasia to high-grade dysplasia and intramucosal cancer.
Anti-reflux surgery may be indicated in symptomatic patients with metaplasia. However, there is no evidence that it prevents progression to dysplasia and cancer so that postoperative surveillance is recommended.
Endoscopic techniques (radiofrequency ablation and endoscopic mucosal resection) are used for most patients with high-grade dysplasia and intramucosal (T1a) cancers, while an esophagectomy is indicated for more advanced stages of the cancer.
A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy. Fourteen individual studies were identified from the past decade that published patient outcome after undergoing an esophagectomy either with or without a pyloric drainage procedure. Careful analysis demonstrated that pyloric drainage procedure was associated with a non-significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was identified between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity.
There are various methods of esophageal cancer surgery. The location of the tumor, the selection of the organ as the esophageal substitute, the route of the conduit, and the level of planned anastomosis are important anatomic factors that surgeons should consider for successful surgery. If the tumor is located in the upper thoracic esophagus, the three-field (cervical, thoracic, and abdominal) approach is usually required to guarantee a sufficient resection margin.In this chapter I describe the surgical techniquefor minimally invasive three-field esophagectomy in detail.
Benign esophageal disease comprises many different diseases and disease pathology including gastroesophageal reflux disease (GERD), hiatal hernia, and achalasia. There are many approaches to treating these diseases including medical and surgical options. The most common symptoms of patients presenting to the primary care doctor include heartburn, dysphagia for solids and/or liquids, regurgitation, chest pain, cough, hoarseness, voice change, and/or weight loss. Multiple studies exist to diagnose these diseases including endoscopy, a 24-hour esophageal ph-metry, esophageal manometry, barium swallow, CXR, real-time video swallow studies, and/or CT scan with oral contrast. Not all studies are needed, and the choice depends on the patient and surgeon preference. Treatment options exist including minimally invasive surgical techniques to reduce a hiatal hernia, fundoplication (Nissen 360°; Toupet 270°; Dor 180°), and/or Heller myotomy. Most patients tolerate these procedures well with high success rates, minimal postoperative pain, short hospital stays, and a quick return to daily activities. In symptomatic patients, surgery offers an excellent option for definitive therapy in appropriately selected patients.
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Surgical techniques for esophagectomy have evolved greatly since the first esophagectomy was described in 1913. The following chapter outlines the principles of esophageal resection and reconstruction and details the techniques of the various approaches to esophagectomy including transhiatal esophagectomy, Ivor Lewis esophagectomy, Hole McKeown esophagectomy, and minimally invasive esophagectomy. This chapter also discusses common complications after esophagectomy and management strategies.
Background:
Delayed gastric emptying (DGE) is a common complication after esophagectomy with gastric tube reconstruction. It is still unclear whether a pyloric drainage procedure might reduce the risk of DGE.
Methods:
We identified in our database all patients subjected to Ivor Lewis esophagectomy after neoadjuvant chemoradiotherapy in the period 2000-2012. In the period 2000-2009, we performed a routine pyloroplasty (pyloroplasty group, PP group, 15 patients), after 2009 we did not perform any type of pyloric drainage procedure (nonpyloroplasty group, NPP group, 11 patients). We compared the groups with subjective questionnaires to assess the perceived quality of life (QoL) (QLQ-C30 and OES-18) and with objective test to study the gastric tube emptying (timed barium swallow test, scintigraphy, 24 hours' pH-metry).
Results:
No difference was observed in questionnaires QLC-C30 and OES-18 scores: 73% of patients in PP group and 63% in NPP group scored their overall QoL as good to excellent (QLC-C30). We did not report difference in timed barium swallow test results and in scintigraphy results. Twenty-four-hour pH-metry results showed in PP group a nonsignificant higher number of acid reflux episodes (NPP group 23.2 ± 9.5 versus PP group 41.3 ± 10.7, P = .29) and a longer time with pH <4 (NPP group 0.89% ± 1.6% versus PP group 3.1% ± 2.1%, P = .24).
Conclusions:
In our series, pyloroplasty was not associated with improved long-term QoL nor with better gastric conduit emptying. Further studies are needed to confirm these findings.
Background
Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients.
Methods
The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student’s t test, χ ² analysis, and Mann–Whitney U test where appropriate.
Results
The study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p > 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention.
Conclusions
In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.
Sleeve gastrectomy (SG) has been accepted as an option for surgical treatment for obesity. This operation could be associated with motor gastric dysfunction and abnormal gastric emptying. The purpose of this prospective study is to present the results of gastric emptying to liquids and solids using scintigraphy in patients who underwent SG compared to normal subjects.
Twenty obese patients were submitted to laparoscopic SG and were compared to 18 normal subjects. Gastric emptying of liquids and solids was measured by scintigraphic technique. Results were expressed as half time of gastric emptying and the percentage of retention at 20, 30, and 60 min for liquids and at 60, 90, and 120 min for solids.
In the group of operated patients, 70% of them (n = 14) presented accelerated emptying for liquids and 75% (n = 15) for solids compared to 22.2% and 27.7%, respectively, in the control group. The half time of gastric emptying (T (1/2)) in patients submitted to SG both for liquids and solids were significantly more accelerated compared to the control group (34.9 +/- 24.6 vs 13.6 +/- 11.9 min for liquids and 78 +/- 15.01 vs 38.3 +/- 18.77 min for solids; p < 0.01). The gastric emptying for liquids expressed as the percentage of retention at 20, 30, and 60 min was 30.0 +/- 0.25%, 15.4 +/- 0.18%, and 5.7 +/- 0.10%, respectively, in operated patients, significantly less than the control subjects (p < 0.001). For solids, the percentage of retention at 60, 90, and 120 min was 56 +/- 28%, 34 +/- 22%, and 12 +/- 8%, respectively, for controls, while it was 25.3 +/- 0.20%, 9 +/- 0.12%, and 3 +/- 0.05%, respectively, in operated patients (p < 001).
Gastric emptying after SG is accelerated either for liquids as well as for solids in the majority of patients. These results could be taken in consideration for the dietary indications after surgery and could play a significant role in the definitive results during the late follow-up.
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Impaired gastric emptying after esophagectomy contributes to significant morbidity and delayed recovery. Traditional measures to prevent this include pyloromyotomy and pyloroplasty. These procedures are associated with known complications and do not always prevent delayed gastric emptying. Intrapyloric botulinum toxin injection may be an alternative approach to avoiding pyloric obstruction after esophagectomy.
Patient data were collected in a prospective fashion at a single institution. Forty-eight patients underwent intrapyloric botulinum toxin injection during esophagectomy during a 26-month period (October 2005 to January 2008). Three patients were excluded from analysis because of complications, which interfered with postoperative evaluation of emptying. Forty-five patients were evaluated clinically for signs of delayed gastric emptying. Objective assessment included a dysphagia score in 15, barium swallow in 43, and nuclear gastric emptying scans in 15 patients. The data were also reviewed for evidence of aspiration events leading to pulmonary complications.
Forty-three of 45 patients (96%) had no clinical evidence of delayed gastric emptying in the immediate postoperative period. Four barium studies were interpreted as delayed gastric emptying; however, only 2 patients were symptomatic. These 2 patients underwent balloon pyloric dilation, which resulted in resolution of symptoms in 1. Three additional patients exhibited "late" delayed gastric emptying after initially doing well (mean of 3 months postoperatively) and required endoscopic intervention. No complications were identified in the study related to botulinum toxin injection.
Intrapyloric injection with botulinum toxin is a simple, safe, and effective means of avoiding delayed gastric emptying after esophagectomy. When necessary, reintervention may be performed endoscopically.
To review the outcomes of 104 consecutive minimally invasive esophagectomy (MIE) procedures for the treatment of benign and malignant esophageal disease.
Although minimally invasive surgical approaches to esophagectomy have been reported since 1992, MIE is still considered investigational at most institutions.
This prospective study evaluates 104 MIE procedures performed between August 1998 and September 2007. Main outcome measures include operative techniques, operative times, blood loss, length of stay, conversion rates, morbidities, and mortalities.
Indications for surgery were esophageal cancer (n = 80), Barrett esophagus with high-grade dysplasia (n = 6), recalcitrant stricture (n = 8), gastrointestinal stromal tumor (n = 3), and gastric cardia cancer (n = 7). Surgical approaches included thoracoscopic/laparoscopic esophagectomy with a cervical anastomosis (n = 47), minimally invasive Ivor Lewis esophagectomy (n = 51), laparoscopic hand-assisted blunt transhiatal esophagectomy (n = 5), and laparoscopic proximal gastrectomy (n = 1). There were 77 males. The mean age was 65 years. Three patients (2.9%) required conversion to a laparotomy. The median ICU and hospital stays were 2 and 8 days, respectively. Major complications occurred in 12.5% of patients and minor complications in 15.4% of patients. The incidence of leak was 9.6% and of anastomotic stricture was 26%. The 30-day mortality was 1.9% with an in-hospital mortality of 2.9%. The mean number of lymph nodes retrieved was 13.8.
Minimally invasive esophagectomy is feasible with a low conversion rate, acceptable morbidity, and low mortality. Our preferred operative approach is the laparoscopic\thoracoscopic Ivor Lewis resection, which provides a tension-free intrathoracic anastomosis.
In a prospective randomized study of pyloroplasty versus no drainage, 200 patients (100 in each group) in whom the whole stomach was used for reconstruction following resection for esophageal carcinoma were studied. Only patients who underwent the Lewis-Tanner operation and who had a normal pylorus were included. There was no morbidity from the pyloroplasty procedure. Thirteen patients without drainage developed symptoms of gastric outlet obstruction, requiring prolonged post-operative parenteral nutrition, and reoperation was required in one patient. Four patients developed pulmonary complications associated with gastric distension, which resulted in fatal aspiration in two patients. Five patients had symptoms of outlet obstruction with eating at the time of their death. Mean and standard deviation of daily gastric aspirate was 161 +/- 88 mL in the pyloroplasty group and 233 +/- 142 mL for the control group (p = 0.23). Gastric emptying test showed mean T1/2 +/- standard deviation of 6.6 +/- 7.5 minutes in the pyloroplasty group and 24.3 +/- 31.5 minutes in the control group (p less than 0.001). More patients in the pyloroplasty group were able to tolerate a solid diet and at normal or increased amounts than were patients in the control group in the early postoperative weeks (p less than 0.01). In addition, control patients were found to have increased symptoms with meals, which were more frequent and of greater severity than symptoms in patients in the pyloroplasty group, even at 6 months after surgery (p less than 0.01). Therefore, we recommend a pyloroplasty for patients in whom the whole stomach is used for reconstruction after esophagectomy.
A prospective, randomized, controlled trial comparing clinical outcome and emptying of a solid meal from the retrosternal stomach, with and without pyloroplasty is described. Forty consecutive patients with oesophageal cancer undergoing retrosternal gastric reconstruction of the oesophagus were studied. In 20 patients the pylorus was left intact (group 1) and 20 patients underwent an Aust pyloroplasty (group 2). Nine patients in group 1 suffered postoperative symptoms of gastric stasis compared with only one patient in group 2 (P = 0.0106). Three patients in group 1 died from aspiration pneumonia before discharge from hospital. A gastric emptying test was performed on 24 patients between 1 and 3 months after surgery. By this time, most survivors had recovered from symptoms attributed to gastric stasis and no significant difference in gastric emptying could be demonstrated between the two groups. Selection of patients, a wide range of emptying times and improvement in gastric emptying on follow-up may explain the lack of correlation between postoperative symptomatology and the gastric half-emptying times. A pyloroplasty is advised to prevent the potentially lethal effects of gastric stasis in the early postoperative period following retrosternal reconstruction of the oesophagus.
A randomized, prospective, controlled trial compared the use of pyloroplasty (study group) with nonuse of the procedure (control group) in the treatment of 72 patients with carcinoma of the thoracic esophagus. In these patients, transthoracic esophagectomy was performed, and the whole stomach was used for reconstruction in the right side of the chest. No complications due to the pyloroplasty developed in any of the patients who underwent this procedure. Gastric emptying tests that were performed at the sixth postoperative month in 37 patients demonstrated a prolongation of emptying time in the control group (p less than 0.01). The patients' symptoms, however, did not correlate well with gastric emptying time. Follow-up assessment showed that a higher proportion of patients who did not undergo pyloroplasty suffered from symptoms of incomplete emptying while eating, but the difference was not statistically significant. Moreover, the proportion of patients who were free of postoperative symptoms gradually increased in both groups and reached 100% in the study group and 89% in the control group at 2 years. In the control group, two of the three patients with prolonged gastric emptying time complained of persistent regurgitation and distending discomfort after meals (18 and 24 months after surgery). They were the only two patients who might have benefited from a drainage procedure at the initial operation. Since there apparently were no reliable operative criteria by which to identify patients who might require drainage, and since the risk associated with pyloroplasty was negligible, it would seem reasonable to perform a pyloroplasty on every patient in whom the whole stomach was used for reconstruction after esophagectomy. This procedure would benefit the few patients who might manifest symptomatic gastric stasis.
The effects of pyloroplasty following subtotal oesophagectomy and gastric substitution with cervical oesophago-gastric anastomosis were studied in a prospective randomized trial. 52 patients received extramucosal pyloroplasty and were compared to a control group of 55 patients, in whom no drainage procedure was performed. 6 patients died postoperatively. One of these patients died following the insufficiency of pyloroplasty. The other causes of death were not related to the performance or non-performance of pyloroplasty. Regarding to patients subjective self-assessment of abdominal discomfort and radiologic emptying of the gastric tube no statistical significant differences between both groups were noted 2 weeks and 6 months postoperatively. Two patients with pyloroplasty, but no patient of the control group, suffered 12 months postoperatively from severe vomiting due to fibrotic stricture of the pylorus. The results of this study suggest, that usually no pyloroplasty should be performed following subtotal oesophagectomy and interposition of a gastric tube with oesophagogastric anastomosis in the neck.
Delayed emptying of the gastric substitute is a common problem after resection and reconstruction of the esophagus. The occurrence of postoperative delayed gastric emptying in patients undergoing resection and reconstruction of the esophagus was studied with regard to the type and size of gastric substitute and the execution of a pyloroplasty.
From 1983 to 1994, one hundred fifty-five patients underwent resection of the esophagus, with a hospital mortality rate of 7 percent. The inability to resume a diet of solid food within one week after a normal esophagography was defined as delayed gastric emptying. One hundred forty patients were studied; group 1, substitution with whole stomach with (1a, n = 9) and without (1b, n = 31) pyloroplasty; group 2, substitution with distal two-thirds stomach with (2a, n = 20) or without (2b, n = 45) pyloroplasty; and group 3, tubulized stomach without pyloroplasty (n = 35).
Delayed gastric emptying was seen in 38 percent (15 of 40) of patients in group 1 (1a, 44 percent; 1b, 37 percent), in 14 percent (nine of 65) of patients in group 2 (1a, 10 percent; 2b, 15 percent), and in 3 percent (one of 35) of patients in group 3. The differences between patients in group 1 and group 2, and between patients in group 1 and group 3 were significantly different (p < 0.05).
The type of gastric remnant used for reconstruction is an important determinant of postoperative gastric emptying. Pyloroplasty does not prevent delayed gastric emptying after esophageal substitution.
After resection of esophageal carcinoma, pyloroplasty was undergone due to vagal denervation. Especially the ability of oral-taking is related to the return of general societies after operation. This was a randomized study on whether pyloroplasty was effective by functional and nutritional evaluations. From 1992 to 1995, 67 patients with esophageal carcinoma underwent subtotal esophagectomy and reconstruction using a gastric tube. Thirty-four patients were randomized into the pyloroplasty group (P), and 33 into the control group (N). The functional evaluation was done with (1) food-taking scoring (2) A foods with barium granules ejection time (3) a gastric emptying time of 99m Technecium (4) 75 g OGTT. The nutritional evaluation were (1) Rapid Turn-over Protein (RTP) (2) Total Lymphocyte Count (TLC) (3) ONODERA's Prognostic Nutritional Count (PNI) (4) Fluctuation rate of body weight. The elevations were performed 1 and 6 months after operation. Functional evaluation were as follows. (1) Quantity of oral-intake was not significant different between (P) and (N) both improving those quantities in 6 months. Regarding several complaints including in regurgitation, (P) had a few symptoms comparing to (N), almost half of cases complained of some symptoms and did not improving in 6 months. (2) The food ejection time of foods were 19.6 +/- 31.0 min, in (P), 32.9 +/- 37.2 min, in (N), (3) In the Tc gastric emptying time, we calculated as 50% ejecting time and residual rate of 30 min. In 50% ejecting time less than 20 min., (P) shared in 65, 80%, (N) in 39, 40% in 1 and 6 months. (4) In 75 g OGTT there were no significant difference between both groups, though several cases showed the dumping syndrome. In the nutritional evaluation, in RTP, TLC, PNI, and postope, body weight, there were no differences between the two groups. In conclusion, pyloroplasty several symptoms related to oral intake including regurgitation feelings, and in functional evaluation, there shows faster gastric emptying though there were no significant differences in the nutritional phases at 6 months follow-up. The results suggest that this procedure is not essential but it affects to the oral-intake QOL effectively.
To assess our outcomes after minimally invasive esophagectomy (MIE).
Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases.
From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214).
There were 186 men and 36 women. Median age was 66.5 years (range, 39-89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1-30); hospital stay was 7 days (range, 3-75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1-68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series.
MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.
Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation.
Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage.
The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96).
Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.
Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy.
One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed.
Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis.
Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.
Delayed gastric emptying after esophageal operations occurs in up to 50% of patients. A good quality of life, in long-term survivors after esophagectomy, may depend on both dietary adaptation and the improvement of intrathoracic gastric motility itself. The objective of this study was to investigate the effect of pyloric balloon dilatation on the sustained delay of gastric emptying after esophagectomy.
Two hundred and fifty-seven patients underwent esophagectomy with a gastric conduit from January 2003 to December 2006. A gastric drainage procedure was routinely performed during the esophagectomy. The intrathoracic gastric emptying of solid food was evaluated by radioisotope imaging. A 50% gastric emptying time over 180 min was defined as delayed. We assessed the changes of the intrathoracic gastric emptying time, and the symptoms after balloon dilatation of the pylorus, associated with delayed gastric emptying.
Balloon dilatation of the pylorus was performed in 21 patients (8%) who had sustained symptoms of delayed gastric emptying after esophagectomy for esophageal cancer despite the use of prokinetics. The symptoms associated with delayed gastric emptying were improved after balloon dilatation of the pylorus in all patients. Pyloric balloon dilatation was performed twice in two patients. In seven of 19 patients (37%), who had a follow-up gastric emptying study, the delayed gastric emptying rate for 180 min was improved from 30% to 88%. Six patients had slightly improved results, and six patients had no increase in the rate of gastric emptying compared with the previous gastric emptying study.
After balloon dilatation of the pylorus, two thirds of patients with delayed gastric emptying show increased rates of gastric emptying as measured by radioisotope imaging. Mechanical balloon dilatation of the pylorus is a useful method to treat sustained delay of intrathoracic gastric emptying after esophagectomy.