Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy

Tk, Chattopadhyay; Shad, Sadaf; Kumar, Arvind

doi:10.1002/bjs.1800800336

Cited by 25 publications

(12 citation statements)

References 12 publications

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“…The two trial assessors agreed on the selection of nine RCTs [8, 9, 11, 12, 13, 14, 15, 18, 19]. Combining these trials yielded data on 553 patients.…”

Section: Resultsmentioning

confidence: 99%

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Pyloric Drainage (Pyloroplasty) or No Drainage in Gastric Reconstruction after Esophagectomy: A Meta-Analysis of Randomized Controlled Trials

Urschel¹,

Blewett²,

Young³

et al. 2002

Dig Surg

166

112

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Background/Aim: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. The gastric emptying may be impaired after this operation, so some esophageal surgeons routinely add a pyloric drainage procedure (pyloroplasty or pyloromyotomy). We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of pyloric drainage on patient outcomes. Methods: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of pyloric drainage procedures during gastric conduit reconstruction of the esophagus. The selection process was inclusive; no trials were excluded. Trial validity assessment was done, and a trial quality score was assigned. Early outcomes assessed by meta-analysis included operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, pyloric drainage complications, fatal pulmonary aspiration, and gastric outlet obstruction. A random-effects model was used, and the relative risk was the principal measure of effect. Systematic semiquantitative review was used for late outcomes such as gastric emptying, bile reflux, nutritional status, and obstructive foregut symptoms. Results: Nine RCTs, that included a total of 553 patients, were selected, with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. The relative risk (95% CI; p value), expressed as pyloric drainage versus no drainage (treatment vs. control), was 0.92 (0.34, 2.44; p = 0.86) for operative mortality, 0.90 (0.47, 1.76; p = 0.77) for esophagogastric anastomotic leaks, 0.69 (0.42, 1.14; p = 0.15) for pulmonary morbidity, 2.55 (0.34, 18.98; p = 0.36) for pyloric drainage complications, 0.25 (0.04, 1.60; p = 0.14) for fatal pulmonary aspiration, and 0.18 (0.03, 0.97; p = 0.046) for gastric outlet obstruction. Systematic semiquantitative review showed a nonsignificant trend favoring pyloric drainage for the late outcomes of gastric emptying, nutritional status, and obstructive foregut symptoms. For the late outcome of bile reflux, there was a nonsignificant trend favoring the no-drainage group. The scintographic gastric emptying time, expressed as a ratio (pyloric drainage/no drainage), was 0.53. Conclusions: Data synthesized from existing RCTs show that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.

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“…The two trial assessors agreed on the selection of nine RCTs [8, 9, 11, 12, 13, 14, 15, 18, 19]. Combining these trials yielded data on 553 patients.…”

Section: Resultsmentioning

confidence: 99%

“…This set was limited to ‘randomized controlled trial’ in the ‘publication type’ search field. This final search step produced eleven citations [7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17]. …”

Section: Methodsmentioning

confidence: 99%

Pyloric Drainage (Pyloroplasty) or No Drainage in Gastric Reconstruction after Esophagectomy: A Meta-Analysis of Randomized Controlled Trials

Urschel¹,

Blewett²,

Young³

et al. 2002

Dig Surg

166

112

View full text Add to dashboard Cite

show abstract

“…Kobayashi et al 16 noted a significant reduction in regurgitation and reflux symptoms in patients in whom a drainage procedure had been performed, compared with those without. In another study, 24 patients were assigned randomly to pyloric drainage or not, and it was found that pyloroplasty made no difference to symptoms of reflux or the mean concentration of bile in gastric fluid at 6 months after subtotal oesophagectomy and intrathoracic anastomosis 17 .…”

Section: Pyloric Drainage Proceduresmentioning

confidence: 99%

Reflux after oesophagectomy

Aly

Jamieson

2004

British Journal of Surgery

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Reflux after oesophagectomy is a significant problem, with both clinical and pathological consequences. Simple measures to facilitate gastric emptying, such as creating a gastric tube, performing a pyloric drainage procedure and using gastric motility agents, may produce a reduction in symptoms but do not alone control reflux itself. A variety of surgical reconstructions have been used, many of which are either difficult to fashion or not suitable when a radical resection has been performed. A modified fundoplication at the anastomosis seems to be the simplest technique and may be relatively effective in controlling symptoms. The impact of strategies to reduce reflux on quality of life and on pathological sequelae of reflux in the oesophageal remnant remains to be evaluated.

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“…24 The suggestion that bile reflux is worse after interference with the pylorus was not substantiated by quantitative measurement in a small RCT. 25 Hill et al showed that the administration of erythromycin (but not cisapride or fashioning a pyloroplasty) significantly improved gastric emptying after oesophagectomy. 26 We construct a tubular conduit and administer erythromycin (oral syrup); none of our patients have required any pyloric intervention, either surgical or endoscopic, or suffered from significant long-term symptoms of delayed gastric emptying.…”

Section: 21mentioning

confidence: 99%

A personal perspective on controversies in the surgical management of oesophageal cancer

Manson

Beasley

2014

annals

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Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis. KEYWORDSOesophagectomy -Ivor-Lewis -Oesophageal cancer -Gastro-oesophageal anastomosisPyloroplasty -Lymphadenectomy The aim of this paper is to outline and justify the approach we favour for oesophageal resection in malignant disease. In order to accomplish this aim, we draw on our own experience 1 and review of the relevant literature. Surgical approachPerhaps because the oesophagus is present in the neck, the thorax and the abdomen, multiple surgical approaches (and combination of approaches) to oesophageal resection are described. Inevitably, there is controversy over the optimal approach. We favour a laparotomy and right lateral thoracotomy. This is preferred to other approaches such as a threestage, transhiatal or minimally invasive oesophagectomy (MIO).In the three-stage (McKeown) approach, gastro-oesophagectomy is followed by a further cervical incision and an anastomosis fashioned in the neck. We are unable to identify any compelling argument to support this approach. It is claimed that anastomosis is technically easier in the neck than in the chest. In south Wales, the majority of patients with oesophageal cancer are overweight with a barrel chest and a short neck. In our experience, no matter how high in the chest it located, an intrathoracic anastomosis is unarguably technically easier than in the neck.It is also argued that anastomotic leakage following cervical anastomosis is less dangerous than in the chest. Not all oesophageal surgeons accept this. There is evidence that a cervical anastomosis often comes to lie in the upper part of the thoracic cavity.2 Since our rate of anastomotic leakage is, fortunately, very low (overall leak rate 1.2%, clinical leak rate 0.6%), this is not an issue in our practice.A further potential argument in favour of the three-stage approach is a greater proximal resection margin; the advantage has been estimated at 1cm.2 No patient in our series had an involved proximal margin, which suggests that adequate clearance can be obtained with an intrathoracic approach. The majority of the available evidence suggests that the rate of benign anastomotic stricture is significantly lower in intrathoracic than in cervical anastomoses.3-5 (See 'Anastomotic technique' section below.) We can identify no advantages to a three-stage procedure. In our series of 165 patients, access to the neck was needed in only two patients who developed significant complications. It is claimed that a transhiatal approach to oesophageal resection is associated wi...

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Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy

Cited by 25 publications

References 12 publications

Pyloric Drainage (Pyloroplasty) or No Drainage in Gastric Reconstruction after Esophagectomy: A Meta-Analysis of Randomized Controlled Trials

Pyloric Drainage (Pyloroplasty) or No Drainage in Gastric Reconstruction after Esophagectomy: A Meta-Analysis of Randomized Controlled Trials

Reflux after oesophagectomy

A personal perspective on controversies in the surgical management of oesophageal cancer

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