Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study

  • Salvatore Marchese
  • Yassar A. Qureshi
  • Shazia P. Hafiz
  • Khaled Dawas
  • Paul Turner
  • M. Muntzer Mughal
  • Borzoueh Mohammadi
Original Article
  • 6 Downloads

Abstract

Background

Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus.

Methods

A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment.

Results

Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively).

Conclusion

We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.

Keywords

Oesophagectomy Pyloric drainage Pyloroplasty Botulinum toxin Delayed gastric emptying 

Notes

Author Contribution

Each author has participated significantly in the work and takes public responsibility for it.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Fuchs HF, Broderick RC, Harnsberger CR, Divo FA, Coker AM, Jacobsen GR, Sandler BJ, Bouvet M, Horgan S. Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation. J Laparoendosc Adv Surg Tech A. 2016 Jun;26(6):433–8.  https://doi.org/10.1089/lap.2015.0575. Epub 2016 Apr 4.
  2. 2.
    Antonoff MB, Puri V, Meyers BF, Baumgartner K, Bell JM, Broderick S, Krupnick AS, Kreisel D, Patterson GA, Crabtree TD. Comparison of pyloric intervention strategies at the time of esophagectomy: is more better? Ann Thorac Surg. 2014 Jun;97(6):1950–7; discussion 1657-8.  https://doi.org/10.1016/j.athoracsur.2014.02.046. Epub 2014 Apr 21.
  3. 3.
    Swanson EW, Swanson SJ, Swanson RS. Endoscopic pyloric balloon dilatation obviates the need for pyloroplasty at esophagectomy. Surg Endosc. 2012 Jul;26(7):2023–8.  https://doi.org/10.1007/s00464-012-2151-5. Epub 2012 Mar 8.
  4. 4.
    Akkerman RD, Haverkamp L, van Hillegersberg R, Ruurda JP. Surgical techniques to prevent delayed gastric emptying after esophagectomy with gastric interposition: a systematic review. Ann Thorac Surg. 2014 Oct;98(4):1512–9.  https://doi.org/10.1016/j.athoracsur.2014.06.057. Epub 2014 Aug 22.
  5. 5.
    Eldaif SM, Lee R, Adams KN, Kilgo PD, Gruszynski MA, Force SD, Pickens A, Fernandez FG, Luu TD, Miller DL. Intrapyloric botulinum injection increases postoperative esophagectomy complications. Ann Thorac Surg. 2014 Jun;97(6):1959–64; discussion 1964-5.  https://doi.org/10.1016/j.athoracsur.2013.11.026. Epub 2014 May 1.
  6. 6.
    Giugliano DN, Berger AC, Meidl H, Pucci MJ, Rosato EL, Keith SW, Evans NR, Palazzo F. Do intraoperative pyloric interventions predict the need for postoperative endoscopic interventions after minimally invasive esophagectomy? Dis Esophagus. 2017 Apr 1;30(4):1–8.  https://doi.org/10.1093/dote/dow034. CrossRefPubMedGoogle Scholar
  7. 7.
    Arya S, Markar SR, Karthikesalingam A, Hanna GB. The impact of pyloric drainage on clinical outcome following esophagectomy: a systematic review. Dis Esophagus. 2015 May-Jun;28(4):326–35.  https://doi.org/10.1111/dote.12191. Epub 2014 Feb 24.
  8. 8.
    Gaur P, Swanson SJ. Should we continue to drain the pylorus in patients undergoing an esophagectomy? Dis Esophagus. 2014 Aug;27(6):568–73.  https://doi.org/10.1111/dote.12035. Epub 2013 Feb 26. Review.
  9. 9.
    Urschel JD, Blewett CJ, Young JE, Miller JD, Bennett WF. Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials. Dig Surg. 2002;19(3):160–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Khan OA, Manners J, Rengarajan A, Dunning J. Does pyloroplasty following esophagectomy improve early clinical outcomes? Interact Cardiovasc Thorac Surg. 2007 Apr;6(2):247–50. Epub 2006 Dec 18.Google Scholar
  11. 11.
    Mohajeri G, Tabatabaei SA, Hashemi SM, Hemmati H. Comparison of pyloromyotomy, pyloric buginage, and intact pylorus on gastric drainage in gastric pull-up surgery after esophagectomy. J Res Med Sci. 2016 May 9;21:33. eCollection 2016.Google Scholar
  12. 12.
    Raymond D. Complications of esophagectomy. Surg Clin North Am. 2012 Oct;92(5):1299–313.  https://doi.org/10.1016/j.suc.2012.07.007.CrossRefPubMedGoogle Scholar
  13. 13.
    Palmes D, Weilinghoff M, Colombo-Benkmann M, Senninger N, Bruewer M. Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction. Langenbecks Arch Surg. 2007 Mar;392(2):135–41. Epub 2007 Jan 10.Google Scholar
  14. 14.
    Stewart CL, Wilson L, Hamm A, Bartsch C, Boniface M, Gleisner A, Mitchell JD, Weyant MJ, Meguid R, Gajdos C, Edil BH, McCarter M. Is Chemical Pyloroplasty Necessary for Minimally Invasive Esophagectomy? Ann Surg Oncol. 2017 May;24(5):1414–1418.  https://doi.org/10.1245/s10434-016-5742-x. Epub 2017 Jan 5.
  15. 15.
    Mahmodlou R, Badpa N, Nosair E, Shafipour H, Ghasemi-Rad M. Usefulness of Pyloromyotomy With Transhiatal Esophagectomy in Improving Gastric Emptying. Gastroenterology Res. 2011 Oct;4(5):223–227. Epub 2011 Sep 20.Google Scholar
  16. 16.
    Dragstedt LR. Some physiologic principles involved in the surgical treatment of gastric and duodenal ulcer. Ann Surg. 1935 Oct;102(4):563–80.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Bagheri R, Fattahi SH, Haghi SZ, Aryana K, Aryanniya A, Akhlaghi S, Riyabi FN, Sheibani S. Botulinum toxin for prevention of delayed gastric emptying after esophagectomy. Asian Cardiovasc Thorac Ann. 2013 Dec;21(6):689–92.  https://doi.org/10.1177/0218492312468438. Epub 2013 Jul 11.
  18. 18.
    Kent MS, Pennathur A, Fabian T, McKelvey A, Schuchert MJ, Luketich JD, Landreneau RJ. A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy. Surg Endosc. 2007 May;21(5):754-7. Epub 2007 Feb 16. Erratum in: Surg Endosc. 2007 Nov;21(11):2120.Google Scholar
  19. 19.
    Datta J, Williams NN, Conway RG, Dempsey DT, Morris JB. Rescue pyloroplasty for refractory delayed gastric emptying following esophagectomy. Surgery. 2014 Aug;156(2):290-7.  https://doi.org/10.1016/j.surg.2014.03.014. Epub 2014 Mar 14.

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  1. 1.Department of Oesophago-Gastric SurgeryUniversity College Hospital, University College London HospitalsLondonUK
  2. 2.Upper Gastrointestinal ServiceRoyal Preston Hospital, Lancashire Teaching HospitalsPrestonUK

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