Pylorus drainage procedures in thoracoabdominal esophagectomy – a single-center experience and review of the literature

Abstract

BackgroundPylorotomy and pyloroplasty in thoracoabdominal esophagectomy are routinely performed in many high-volume centers to prevent delayed gastric emptying (DGE) due to truncal vagotomy. Currently, controversy remains regarding the need for these practices. The present study aimed to determine the value and role of pyloric drainage procedures in esophagectomy with gastric replacement.MethodsA retrospective review of prospectively collected data was performed for all consecutive patients who underwent thoracoabdominal resection of the esophagus between January 2009 and December 2016 at the Katharinenhospital in Stuttgart, Germany. Clinicopathologic features and surgical outcomes were evaluated with a focus on postoperative nutrition and gastric emptying.ResultsThe study group included 170 patients who underwent thoracoabdominal esophageal resection with a gastric conduit using the Ivor Lewis approach. The median age of the patients was 64 years. Most patients were male (81%), and most suffered from adenocarcinoma of the esophagus (75%). The median hospital stay was 20 days, and the 30-day hospital death rate was 2.9%. According to the department standard, pylorotomy, pyloroplasty, or other pyloric drainage procedures were not performed in any of the patients. Overall, 28/170 patients showed clinical signs of DGE (16.5%).ConclusionsIn the literature, the rate of DGE after thoracoabdominal esophagectomy is reported to be approximately 15%, even with the use of pyloric drainage procedures. This rate is comparable to that reported in the present series in which no pyloric drainage procedures were performed. Therefore, we believe that pyloric drainage procedures may be unwarranted in thoracoabdominal esophagectomy. However, future randomized trials are needed to ultimately confirm this supposition.

Delayed Gastric Emptying after Esophagectomy: Management and Prevention

“…Pyloric interventions have been thought of as the major form of prophylaxis against DGE. There are 5 pyloric management strategies at the time of esophagectomy: no intervention [52,53], botulinum toxin injection [37], finger fracture [15], pyloroplasty [54], and pyloromyotomy [7,39]. Each method has its advantages and disadvantages, so we cannot say with certainty which one is the best.…”

The Optimal Pyloric Procedure: A Collective Review

“…Although there was no statistically significant difference in the emptying rate or gastric drainage, the authors recommended BT because it is simple, effective, and complication-free. In 2018, Fritz et al [ 40 ] published a retrospective study without a control group. Ivor Lewis operations were performed using a gastric tube and the authors concluded that PD may not be warranted because the complication rate did not differ significantly from that of historical PD studies.…”

Delayed emptying of the gastric conduit after esophagectomy

“…Commonly, the incidence of clinically relevant DGCE is considered to be in the range of 10-20% (16)(17)(18). Manifestation of symptoms of DGCE has however been reported to occur in over 50% of patients after esophagectomy (9,(19)(20)(21).…”