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Wong LY, Rivera MF, Liou DZ, Berry MF. Surgical revision of the postesophagectomy gastric conduit to address poor emptying. JTCVS Tech 2024; 23:132-140. [PMID: 38351992 PMCID: PMC10859648 DOI: 10.1016/j.xjtc.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/25/2023] [Accepted: 11/12/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction The configuration of the gastric conduit after esophagectomy can lead to chronic gastrointestinal and respiratory issues. Surgical revision of the gastric conduit has been described in small series but appears to be infrequently used. We investigated outcomes of revising dilated or redundant conduit in patients with severe quality-of-life issues. Methods We identified all patients from 2016 to 2022 at our institution who underwent gastric conduit revision after previous esophagectomy either at our or another institution. Chart review was performed to assess prerevision course and perioperative outcomes. Pre- and postrevision imaging was compared for all patients to assess the impact of surgery on anatomic configuration. Patient-reported gastrointestinal and respiratory issues before and after surgery were examined. Results The use of right thoracotomy combined with laparotomy to reduce redundancy and improve gastric emptying was performed in 8 patients. The symptoms necessitating reoperation included intolerance to oral intake and poor gastric emptying associated with both acute and chronic aspiration episodes. The median length of stay was 8 [4, 25] days, and there were no perioperative mortalities. Seven (87.5%) patients were tolerating oral intake at discharge. All patients had improvement in their prerevision symptoms on follow-up. Conclusions Gastric conduit revision can improve severe postesophagectomy gastrointestinal and respiratory symptoms in patients with dilated/redundant conduits with limited perioperative morbidity.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Marcos Flores Rivera
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Douglas Z. Liou
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Mark F. Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
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Safarpour D, Jabbari B. Botulinum Toxin Treatment for Cancer-Related Disorders: A Systematic Review. Toxins (Basel) 2023; 15:689. [PMID: 38133193 PMCID: PMC10748363 DOI: 10.3390/toxins15120689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
This systematic review investigates the effect of botulinum neurotoxin (BoNT) therapy on cancer-related disorders. A major bulk of the literature is focused on BoNT's effect on pain at the site of surgery or radiation. All 13 published studies on this issue indicated reduction or cessation of pain at these sites after local injection of BoNTs. Twelve studies addressed the effect of BoNT injection into the pylorus (sphincter between the stomach and the first part of the gut) for the prevention of gastroparesis after local resection of esophageal cancer. In eight studies, BoNT injection was superior to no intervention; three studies found no difference between the two approaches. One study compared the result of intra-pyloric BoNT injection with preventive pyloromyotomy (resection of pyloric muscle fibers). Both approaches reduced gastroparesis, but the surgical approach had more serious side effects. BoNT injection was superior to saline injection in the prevention of esophageal stricture after surgery (34% versus 6%, respectively, p = 0.02) and produced better results (30% versus 40% stricture) compared to steroid (triamcinolone) injection close to the surgical region. All 12 reported studies on the effect of BoNT injection into the parotid region for the reduction in facial sweating during eating (gustatory hyperhidrosis) found that BoNT injections stopped or significantly reduced facial sweating that developed after parotid gland surgery. Six studies showed that BoNT injection into the parotid region prevented the development of or healed the fistulas that developed after parotid gland resection-parotidectomy gustatory hyperhidrosis (Frey syndrome), post-surgical parotid fistula, and sialocele. Eight studies suggested that BoNT injection into masseter muscle reduced or stopped severe jaw pain after the first bite (first bite syndrome) that may develop as a complication of parotidectomy.
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Affiliation(s)
- Delaram Safarpour
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06510, USA
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Hajibandeh S, Hajibandeh S, McKenna M, Jones W, Healy P, Witherspoon J, Blackshaw G, Lewis W, Foliaki A, Abdelrahman T. Effect of intraoperative botulinum toxin injection on delayed gastric emptying and need for endoscopic pyloric intervention following esophagectomy: a systematic review, meta-analysis, and meta-regression analysis. Dis Esophagus 2023; 36:doad053. [PMID: 37539558 DOI: 10.1093/dote/doad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/31/2023] [Indexed: 08/05/2023]
Abstract
The aim of this study was to evaluate the effect of intraoperative botulinum toxin (BT) injection on delayed gastric emptying (DGE) and need for endoscopic pyloric intervention (NEPI) following esophagectomy. In compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a systematic review of studies reporting the outcomes of intraoperative BT injection in patients undergoing esophagectomy for esophageal cancer was conducted. Proportion meta-analysis model was constructed to quantify the risk of the outcomes and direct comparison meta-analysis model was constructed to compare the outcomes between BT injection and no BT injection or surgical pyloroplasty. Meta-regression was modeled to evaluate the effect of variations in different covariates among the individual studies on overall summary proportions. Nine studies enrolling 1070 patients were included. Pooled analyses showed that the risks of DGE and NEPI following intraoperative BT injection were 13.3% (95% confidence interval [CI]: 7.9-18.6%) and 15.2% (95% CI: 7.9-22.5%), respectively. There was no difference between BT injection and no BT injection in terms of DGE (odds ratio [OR]: 0.57, 95% CI: 0.20-1.61, P = 0.29) and NEPI (OR: 1.73, 95% CI: 0.42-7.12, P = 0.45). Moreover, BT injection was comparable to pyloroplasty in terms of DGE (OR: 0.85, 95% CI: 0.35-2.08, P = 0.73) and NEPI (OR: 8.20, 95% CI: 0.63-105.90, P = 0.11). Meta-regression suggested that male gender was negatively associated with the risk of DGE (coefficient: -0.007, P = 0.003). In conclusion, level 2 evidence suggests that intraoperative BT injection may not improve the risk of DGE and NEPI in patients undergoing esophagectomy. The risk of DGE seems to be higher in females and in early postoperative period. High quality randomized controlled trials with robust statistical power are required for definite conclusions. The results of the current study can be used for hypothesis synthesis and power analysis in future prospective trials.
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Matthew McKenna
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - William Jones
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Paul Healy
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Jolene Witherspoon
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Guy Blackshaw
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Wyn Lewis
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Antonio Foliaki
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Tarig Abdelrahman
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
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Endoscopic Intrapyloric Botulinum Toxin Injection with Pyloric Balloon Dilation for Symptoms of Delayed Gastric Emptying after Distal Esophagectomy for Esophageal Cancer: A 10-Year Experience. Cancers (Basel) 2022; 14:cancers14235743. [PMID: 36497224 PMCID: PMC9737592 DOI: 10.3390/cancers14235743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Patients with esophageal cancer undergoing esophagectomy have an improved survival over time, however adverse events associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related complication which can decreased quality of life by causing debilitating gastrointestinal symptoms and malnutrition. The aim of our study was to evaluate the effect of endoscopic intrapyloric botulinum (BT) injection in combination with pyloric balloon dilation in patients with DGE following distal esophagectomy at our tertiary cancer center. Patients with a prior history of distal esophagectomy who had also undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study. One hundred units of BT were injected endoscopically into the pylorus in four quadrants using an injection needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12−20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed. A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. The patients underwent the procedures at a median of 22 months (range, 1−108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times (>2). Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. Eighteen patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) showed no improvement, whereas in two (10%) patients responses were not available. In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex, possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results.
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mertens A, Gooszen J, Fockens P, Voermans R, Gisbertz S, Bredenoord A, van Berge Henegouwen MI. Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation. Dig Surg 2022; 38:337-342. [PMID: 34727541 PMCID: PMC8820434 DOI: 10.1159/000519785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/26/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. METHODS Between 2015 and 2018, patients with delayed gastric emptying 8-10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. RESULTS Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9-15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. CONCLUSION Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.
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Affiliation(s)
- Alexander Mertens
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands,Robotics and Mechatronics, University of Twente, Enschede, The Netherlands,*Alexander Mertens,
| | - Jan Gooszen
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Rogier Voermans
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Suzanne Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Mark Ivo van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands,**Mark Ivo Van Berge Henegouwen,
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Benz C, Martella J, Hamwi B, Okereke I. Factors resulting in postoperative dysphagia following esophagectomy: a narrative review. J Thorac Dis 2021; 13:4511-4518. [PMID: 34422377 PMCID: PMC8339788 DOI: 10.21037/jtd-21-724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/11/2021] [Indexed: 12/03/2022]
Abstract
Esophagectomy is a technically involved surgery and can have significant postoperative morbidity. Although the mortality rate following esophagectomy has decreased in recent years, this surgical procedure has a relatively high complication rate compared to other surgeries to resect cancer. One of the most common complaints after esophagectomy is dysphagia. Dysphagia after esophagectomy can significantly affect quality of life. Dysphagia is a complication following esophagectomy that can lead to respiratory deterioration and death. The most common sites of postoperative dysphagia are the gastroesophageal anastomosis, gastric conduit, pylorus and the hiatus. Without appropriate treatment of dysphagia, malnutrition and dehydration can develop. These factors can lead to significant impacts to the overall health of a patient and increase mortality. A detailed literature review provided data to support diagnostic modalities and management strategies to treat postoperative dysphagia at these common areas. A systematic, evidence-based approach to diagnosis and treatment of postoperative dysphagia allows for prompt intervention and a decrease in morbidity and mortality. Treatment options for dysphagia vary, depending on the etiology. Based on the location and mechanism of dysphagia, options include stenting, dilation and surgical revision. Early treatment of dysphagia after esophagectomy can lessen the morbidity from this complication and improve quality of life.
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Affiliation(s)
- Cecilia Benz
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jessica Martella
- University of Texas Medical Branch School of Medicine, Galveston, TX, USA
| | - Basel Hamwi
- University of Texas Medical Branch School of Medicine, Galveston, TX, USA
| | - Ikenna Okereke
- Division of Thoracic Surgery, Henry Ford Health, Detroit, MI, USA
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8
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Abstract
Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.
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Affiliation(s)
- Thomas Fabian
- Section of Thoracic Surgery, Albany Medical College, Third Floor, 50 New Scotland Avenue, Albany, NY 12159, USA.
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Endoscopic pyloromyotomy in minimally invasive esophagectomy: a novel approach. Surg Endosc 2021; 36:2341-2348. [PMID: 33948713 DOI: 10.1007/s00464-021-08511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pyloric drainage procedures, namely pyloromyotomy or pyloroplasty, have long been considered an integral aspect of esophagectomy. However, the requirement of pyloric drainage in the era of minimally invasive esophagectomy (MIE) has been brought into question. This is in part because of the technical challenges of performing the pyloric drainage laparoscopically, leading many surgical teams to explore other options or to abandon this procedure entirely. We have developed a novel, technically facile, endoscopic approach to pyloromyotomy, and sought to assess the efficacy of this new approach compared to the standard surgical pyloromyotomy. METHODS Patients who underwent MIE for cancer from 01/2010 to 12/2019 were identified from a prospectively maintained institutional database and were divided into two groups according to the pyloric drainage procedure: endoscopic or surgical pyloric drainage. 30-day outcomes (complications, length of stay, readmissions) and pyloric drainage-related outcomes [conduit distension/width, nasogastric tube (NGT) duration and re-insertion, gastric stasis] were compared between groups. RESULTS 94 patients were identified of these 52 patients underwent endoscopic PM and 42 patients underwent surgical PM. The groups were similar with respect to age, gender and comorbidities. There were more Ivor-Lewis esophagectomies in the endoscopic PM group than the surgical PM group [45 (86%), 15 (36%) p < 0.001]. There was no significant difference in the rate of complications and readmissions. Gastric stasis requiring NGT re-insertion was rare in the endoscopic PM group and did not differ significantly from the surgical PM group (1.9-4.7% p = 0.58). CONCLUSIONS Endoscopic pyloromyotomy using a novel approach is a safe, quick and reproducible technique with comparable results to a surgical PM in the setting of MIE.
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10
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Kim D. The Optimal Pyloric Procedure: A Collective Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:233-241. [PMID: 32793458 PMCID: PMC7409877 DOI: 10.5090/kjtcs.2020.53.4.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Dohun Kim
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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11
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Yang HC, Choi JH, Kim MS, Lee JM. Delayed Gastric Emptying after Esophagectomy: Management and Prevention. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:226-232. [PMID: 32793457 PMCID: PMC7409889 DOI: 10.5090/kjtcs.2020.53.4.226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Hee Chul Yang
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jin Ho Choi
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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12
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Abstract
Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.
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Affiliation(s)
- Ammara A Watkins
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA.
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Nevins EJ, Rao R, Nicholson J, Murphy KD, Moore A, Smart HL, Stephens N, Grocock C, Kaul A, Gunasekera RT, Hartley MN, Howes NR. Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy. Ann R Coll Surg Engl 2020; 102:693-696. [PMID: 32538118 DOI: 10.1308/rcsann.2020.0136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment. METHODS All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP. RESULTS Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications. CONCLUSIONS This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.
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Affiliation(s)
- E J Nevins
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R Rao
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - J Nicholson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - K D Murphy
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Moore
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - H L Smart
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N Stephens
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - C Grocock
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Kaul
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R T Gunasekera
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - M N Hartley
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N R Howes
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
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14
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Hasan IS, Mahajan N, Viehman J, Allen MS, Cassivi SD, Lee MK, Nichols FC, Pierson K, Reisenauer JS, Shen RK, Wigle DA, Blackmon SH. Predictors of Patient-Reported Reflux After Esophagectomy. Ann Thorac Surg 2020; 110:1160-1166. [PMID: 32454018 DOI: 10.1016/j.athoracsur.2020.03.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. METHODS A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). RESULTS Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. CONCLUSIONS The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.
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Affiliation(s)
- Irsa S Hasan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita Mahajan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jason Viehman
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Mark S Allen
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Stephen D Cassivi
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minji K Lee
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karlyn Pierson
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Janani S Reisenauer
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert K Shen
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
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15
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Tham JC, Nixon M, Ariyarathenam AV, Humphreys L, Berrisford R, Wheatley T, Sanders G. Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying. Dis Esophagus 2019; 32:5250777. [PMID: 30561584 DOI: 10.1093/dote/doy112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- J C Tham
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - M Nixon
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - A V Ariyarathenam
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - L Humphreys
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - R Berrisford
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - T Wheatley
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - G Sanders
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
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16
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Abstract
With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.
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Affiliation(s)
- Magnus Konradsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
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17
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Shaw L, Bazzell AF, Dains JE. Botulinum Toxin for Side-Effect Management and Prevention of Surgical Complications in Patients Treated for Head and Neck Cancers and Esophageal Cancer. J Adv Pract Oncol 2019; 10:40-52. [PMID: 31308987 PMCID: PMC6605704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The management of head and neck cancers (HNC) and esophageal cancer (EC) is complex and often involves multiple modalities of treatment, including chemotherapy, radiation therapy, and surgery. The side effects associated with these therapies and disease processes are extensive. A literature review was performed to evaluate the use of botulinum toxin as an intervention for side-effect management in patients with HNC and EC. Specific adverse events reviewed included salivary function (hypersalivation, fistula, hyposalivation) and gastrointestinal motility (esophageal stricture, delayed gastric emptying after esophagectomy). Published results demonstrate an improvement in hypersalivation and, when botulinum toxin was used as an adjunct to treatment, a reduction in symptoms associated with salivary fistula, or an inappropriate communication between the salivary gland and the skin that causes the leakage of saliva through the skin. Positive effects were also demonstrated in regard to esophageal stricture and equivalent effects in the management of gastric emptying to prevent complications after esophagectomy when compared to currently available interventions. However, the potential for increased symptoms associated with botulinum toxin injection related to its use in the management of gastric secretions was noted in one of the studies reviewed.
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18
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Abstract
Delayed gastric conduit emptying (DGE) is a common complication after esophagectomy. Currently, pyloric interventions are the major prevention and treatment for DGE. In this review, we attempt to evaluate the clinical effect and safety of different pyloric interventions in esophagectomy patients. Moreover, other important management of DGE, including size of esophageal substitute, erythromycin and nasogastric tube (NGT) will also be discussed.
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Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China
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19
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Nobel T, Tan KS, Barbetta A, Adusumilli P, Bains M, Bott M, Jones D, Molena D. Does pyloric drainage have a role in the era of minimally invasive esophagectomy? Surg Endosc 2018; 33:3218-3227. [PMID: 30535543 DOI: 10.1007/s00464-018-06607-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Tamar Nobel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Kay See Tan
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arianna Barbetta
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manjit Bains
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew Bott
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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20
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Marchese S, Qureshi YA, Hafiz SP, Dawas K, Turner P, Mughal MM, Mohammadi B. Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study. J Gastrointest Surg 2018; 22:1319-1324. [PMID: 29667092 DOI: 10.1007/s11605-018-3759-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/24/2018] [Indexed: 01/31/2023]
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.
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Affiliation(s)
- Salvatore Marchese
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Yassar A Qureshi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Shazia P Hafiz
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Khaled Dawas
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Paul Turner
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - M Muntzer Mughal
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Borzoueh Mohammadi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK.
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21
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Fritz S, Feilhauer K, Schaudt A, Killguss H, Esianu E, Hennig R, Köninger J. Pylorus drainage procedures in thoracoabdominal esophagectomy - a single-center experience and review of the literature. BMC Surg 2018; 18:13. [PMID: 29490701 PMCID: PMC5831596 DOI: 10.1186/s12893-018-0347-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 02/19/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pylorotomy 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. METHODS A 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. RESULTS The 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%). CONCLUSIONS In 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.
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Affiliation(s)
- Stefan Fritz
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Katharina Feilhauer
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - André Schaudt
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Hansjörg Killguss
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Eduard Esianu
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - René Hennig
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Jörg Köninger
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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22
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Perkins VA, McFerran S, Kordzadeh A, Sdralis E, Lorenzi B, Charalabopoulos A. Gastric conduit obstruction due to gastroduodenal compression: a new complication post-Ivor-Lewis oesophagectomy. Acta Chir Belg 2018; 118:59-63. [PMID: 28276285 DOI: 10.1080/00015458.2017.1300007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Oesophagectomy for oesophageal carcinoma carries a high risk of significant morbidity and mortality. Delayed gastric emptying is a relatively common complication following this procedure. A variety of medical, surgical and endoscopic strategies have been described to manage it. The vast majority of cases are related to post-operative pyloric dysfunction and are amenable to conventional management strategies. PATIENTS AND METHODS We present a new case of a patient with a duodenal hiatus hernia resulting in extrinsic gastroduodenal compression by the massively distended gastric conduit as a cause of gastric outlet obstruction following laparoscopic-assisted Ivor-Lewis oesophagectomy 2 years previously. RESULTS AND CONCLUSIONS Surgical repair of the hiatus hernia restored the post-oesophagectomy anatomy and resolved this patient's symptoms where conventional management of post-oesophagectomy gastric outlet obstruction had failed on multiple occasions. Most cases of delayed gastric emptying post-oesophagectomy occur as a result of pyloric dysfunction and can be managed using a combination of prokinetics, surgical intervention or more commonly, endoscopic dilatation. Other potential causes and therefore investigative and management strategies should be considered in patients who repeatedly fail conventional management. We offer an alternative diagnosis that may be considered in these patients and present a novel approach to their investigation and management.
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Affiliation(s)
- Victoria A. Perkins
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, UK
| | - Samuel McFerran
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, UK
| | - Ali Kordzadeh
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, UK
| | - Elias Sdralis
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, UK
| | - Bruno Lorenzi
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, UK
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23
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Rove JY, Krupnick AS, Baciewicz FA, Meyers BF. Gastric conduit revision postesophagectomy: Management for a rare complication. J Thorac Cardiovasc Surg 2017; 154:1450-1458. [DOI: 10.1016/j.jtcvs.2017.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 03/31/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
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24
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Zhang L, Hou SC, Miao JB, Lee H. Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage. J Surg Res 2017; 213:46-50. [PMID: 28601331 DOI: 10.1016/j.jss.2017.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 01/18/2017] [Accepted: 02/14/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND The incidence of delayed gastric emptying (DGE) after esophagectomy is 10%-50%, which can interfere with postoperative recovery in the short-term and result in poor quality of life in the long term. Pyloric drainage is routinely performed to prevent DGE, but its role is highly controversial. The aim of this study was to report the rate of DGE after esophagectomy without pyloric drainage and to investigate its risk factors and the potential effect on recovery. MATERIALS AND METHODS Between January 2010 and January 2015, we analyzed 285 consecutive patients who received an esophagectomy without pyloric drainage. Possible correlations between the incidence of DGE and its potential risk factors were examined in univariate and multivariate analyses, respectively. The outcomes of DGE were reviewed with a follow-up of 3 mo. RESULTS The overall rate of DGE after esophagectomy was 18.2% (52/285). Among perioperative factors, gastric size (gastric tube versus the whole stomach) was the only significant factor affecting the incidence of DGE in the univariate analysis. The patients who received a whole stomach as an esophageal substitute were more likely to develop DGE than were patients with a gastric tube (13.2% versus 22.4%; P = 0.05). No independent risk factor for DGE was found in the multivariate analysis. The incidence of major postoperative complications, including anastomotic leak, respiratory complications, and cardiac complications, was also not significantly different between both groups, with or without DGE. Within 3 mo of follow-up, most patients could effectively manage their DGE through medication (39/52) or endoscopic pyloric dilation (12/52), with only one patient requiring surgical intervention. CONCLUSIONS In our study, the overall incidence of DGE is about 20% for patients undergoing esophagectomy without pyloric drainage. Compared with prior findings, this does not result in a significantly increased incidence of DGE. In patients with symptoms of DGE after esophagectomy, prokinetic agents and endoscopic balloon dilation of the pylorus can be effective, as indicated by the high success rate and lack of significant complications.
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Affiliation(s)
- Lei Zhang
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Sheng-Cai Hou
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jin-Bai Miao
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui Lee
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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25
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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; 24:1414-1418. [PMID: 28058546 DOI: 10.1245/s10434-016-5742-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Lauren Wilson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aidan Hamm
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christan Bartsch
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Boniface
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael J Weyant
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Boshier PR, Huddy JR, Zaninotto G, Hanna GB. Dumping syndrome after esophagectomy: a systematic review of the literature. Dis Esophagus 2017; 30:1-9. [PMID: 27859950 DOI: 10.1111/dote.12488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Piers R Boshier
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Jeremy R Huddy
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
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27
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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; 26:433-8. [PMID: 27043862 DOI: 10.1089/lap.2015.0575] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage. MATERIALS AND METHODS We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality. RESULTS From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05). CONCLUSION Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.
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Affiliation(s)
- Hans F Fuchs
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.,2 Department of Surgery, University of Cologne , Cologne, Germany
| | - Ryan C Broderick
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Cristina R Harnsberger
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Francisco Alvarez Divo
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Alisa M Coker
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Garth R Jacobsen
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
| | - Bryan J Sandler
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.,3 VA Healthcare , San Diego, California
| | - Michael Bouvet
- 4 Department of Surgery, University of California , San Diego, California
| | - Santiago Horgan
- 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California
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