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Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:823-835. [PMID: 36650418 DOI: 10.1007/s11605-022-05573-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy. METHODS PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality. RESULTS There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I2 = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I2 = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I2 = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I2 = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I2 = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I2 = 0%) between the pyloric drainage and no intervention groups. CONCLUSIONS Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.
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Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:3287-3295. [PMID: 36163378 DOI: 10.1007/s00423-022-02685-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure. METHODS A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention. RESULTS Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29). CONCLUSION Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.
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Tham JC, Pournaras DJ, Alcocer B, Forbes R, Ariyarathenam AV, Humphreys ML, Berrisford RG, Wheatley TJ, Chan D, Sanders G, Lewis SJ. Gut hormones profile after an Ivor Lewis gastro-esophagectomy and its relationship to delayed gastric emptying. Dis Esophagus 2022; 35:6544855. [PMID: 35265988 PMCID: PMC9742676 DOI: 10.1093/dote/doac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/03/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022]
Abstract
Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established.
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Affiliation(s)
- Ji Chung Tham
- Address correspondence to: Mr Ji Chung Tham MBChB, MSc, FRCS, C/O Mr Grant Sanders, Level 7, Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth PL6 8DH, UK. Tel: +44(0)1752430011; Fax: +44(0)1752517576;
| | - Dimitri J Pournaras
- Department of Upper Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Bruno Alcocer
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Rosie Forbes
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | | | - Martyn L Humphreys
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | | | - Tim J Wheatley
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - David Chan
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Grant Sanders
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Stephen J Lewis
- Department of Gastroenterology, University Hospital Plymouth, Plymouth, UK
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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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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: 17] [Impact Index Per Article: 2.8] [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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