Management of Delayed Gastric Emptying After Esophagectomy With Endoscopic Balloon Dilatation of the Pylorus

摘要

Statistical AnalysisResultsThis study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit.MethodsA total of 436 patients underwent esophagectomy with gastric conduit from 2002 to 2009. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter, anastomotic location, and mediastinal route were variable. Gastric outlet obstruction (GOO) was strictly defined to include patients with clinical and radiographic delayed gastric emptying requiring intervention.ResultsGastric outlet obstruction was found in 22% (98 of 436) of patients who underwent esophagectomy. Pyloromytomy was performed on 52% (51 of 98) of these patients and employed in 41% (179 of 436) of patients in the entire cohort. GOO was present in 28% (51 of 179) of patients who underwent a pyloric drainage procedure compared with 18% (47 of 257) of patients with no pyloric intervention (p = 0.01). Endoscopic balloon dilatation of the pylorus was used to treat 39% (38 of 98) of patients with delayed gastric emptying yielding a 95% (36 of 98) success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators (range,10 to 20 mm). The remaining patients were treated conservatively with prokinetics, nasogastric drainage, or observation. Nasogastric drainage was employed for 7.4 ± 4.4 days in patients with GOO and 6.8 ± 4.0 days in asymptomatic patients (p = 0.15). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. There was a significant difference in postoperative pneumonia (18.4% vs 10.6%, p = 0.05) and median length of hospital stay (12 ± 16 vs 10 ± 9 days, p < 0.0001) in patients with GOO versus normal emptying.ConclusionsDelayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.CTSNet classification:8Restoration of foregut function after esophagectomy greatly affects patient satisfaction and continues to challenge esophageal surgeons. Surgeons seek to balance the desire to avoid delayed gastric emptying in the early postoperative period against the need to optimize post-esophagectomy long-term foregut function and quality of life. In contrast to dumping syndrome and duodenal gastric reflux, delayed gastric emptying usually occurs early and can significantly influence perioperative morbidity. In an effort to circumvent the pulmonary complications often associated with gastric outlet obstruction (GOO) after esophageal substitution with denervated gastric conduit, pyloric drainage has been advocated by many surgeons despite the long-term functional sequelae. The value of adding pyloric drainage to esophagectomy after gastric conduit reconstruction remains controversial [