Background
Thoracoabdominal esophagectomy for esophageal cancer has been associated with high rates of morbidity and mortality in the past. Until the 1980s, postoperative in-hospital death rates were reported to range around 30% [
1,
2]. Due to significant improvements in surgery, anesthesiology, and intensive care management, a reduction in mortality to less than 10% has been achieved in the last 10–20 years [
3‐
5]. Along with improvements in peri- and postoperative outcomes, surgical techniques have also been evaluated with regard to non-life-threatening postoperative complications and quality of life.
Delayed gastric emptying (DGE) is a frequent functional disorder of the pylorus following esophagectomy with a gastric conduit. Depending on the definition and the surgical technique performed, clinical symptoms during the postoperative course reportedly occur in 10% to 50% of patients [
6,
7]. Gastric outlet obstruction results from truncal vagotomy and is thought to be associated with an increased incidence of postoperative complications, including aspiration with subsequent pneumonia and anastomotic leaks. Consequently, DGE is reported to lead to decreased patient satisfaction and a prolonged hospital stay [
8‐
10].
Although gastric tube reconstruction, rather than reconstruction of the entire stomach, has been sufficiently demonstrated to be associated with a significantly reduced risk of DGE [
11], superior quality-of-life scores during the first postoperative year, and less reflux esophagitis, controversy surrounds the need for pyloric drainage procedures [
9,
12]. Based on historical experience with truncal bilateral vagotomies during peptic ulcer surgery, pyloric drainage procedures were routinely performed in many high-volume centers to prevent DGE. The choice of procedure, including pylorotomy, pyloroplasty, finger fracture, or botulinum toxin injection, mainly depended on the surgeon’s preference. Recent series have questioned the benefit of these procedures [
13]. Currently, ongoing controversy remains concerning the need for pyloric drainage procedures following esophageal substitution with gastric interposition [
8,
14,
15].
Limited data are available on short-term postoperative outcomes regarding DGE following esophagectomy with gastric pull-up. Moreover, most reports are based on series that include patients who underwent surgery in the 1980s and 1990s or even earlier [
16‐
19]. At that time, mortality rates were two- to three-times higher compared to those in more recently published series in high-volume centers. Furthermore, the use of pyloric drainage procedures was based on different surgical schools and not on evidence or randomized clinical trials. In recent years, the rate of laparoscopic esophagectomies has continuously increased. Certainly, pylorus drainage procedures can be performed laparoscopically. However, this technique is relatively sophisticated and may be related to morbidity. Especially for the laparoscopic approach, it is important to be sure whether pylorus drainage procedures will be beneficial compared to no intervention. Therefore, the present study aimed to determine the value and role of pylorus drainage procedures in esophagectomy.
Discussion
DGE is one of the major causes of severe aspiration pneumonia, which is associated with a poor early postoperative outcome following esophagectomy with gastric replacement [
20]. In the past, different surgical techniques, such as pyloromyotomy, pyloroplasty, or pylorus buginage, were implemented to reduce the incidence of gastric outlet obstruction [
14].
Currently, the value of these pyloric drainage procedures remains controversial [
9]. The potential advantage of these procedures is possible prevention of DGE [
21]. Some authors argue that by reducing gastric outlet obstruction, the incidence of aspiration pneumonia may decrease, potentially improving early postoperative outcomes [
17]. Others argue that only a minority of patients show signs of DGE. Furthermore, pyloric drainage procedures may predispose patients to dumping and duodenal reflux, which could impede late postoperative functional outcomes [
14,
20,
22,
23].
In 1991, Fok et al. published a prospective randomized study on 200 patients who underwent esophagectomy with gastric replacement [
17]. Based on their findings, the authors recommended pyloroplasty for patients in whom the entire stomach was used for reconstruction after esophagectomy. These results are not comparable to those of more recent studies because most centers today do not use the entire stomach for esophageal replacement but only a small conduit of 3–5 cm in diameter [
11]. By analyzing 2 RCTs and 5 cohort studies, Akkermann et al. found that the overall rate of DGE was significantly lower in patients who underwent gastric tube reconstruction compared with that in patients who underwent reconstruction using the whole stomach [
9].
In 2002, Urschel et al. performed a meta-analysis including nine randomized controlled trials with a total of 553 patients [
21]. According to this study, pyloric drainage procedures at the time of esophagectomy reduced the occurrence of early gastric outlet obstruction (
p = 0.046) but had little effect on mortality, pulmonary complications and late postoperative foregut function.
Although two recent systematic reviews including 827 and 668 patients did not find a benefit of pyloric drainage procedures versus no intervention [
9,
15], Arya et al. found a non-significant trend toward fewer anastomotic leaks, fewer pulmonary complications and less gastric stasis when pyloric drainage procedures were performed [
8]. However, most studies included in these systematic reviews were performed at a time when the morbidity and mortality rates of esophagectomy were generally much higher compared to today. For example, the study of Akkerman et al. included patients who underwent surgery in the 1980s and 1990s or even earlier [
9]. As mentioned above, the postoperative outcomes of these patients are not comparable to those of current studies due to improvements in intensive care and relevant modifications of operative techniques, including minimally invasive approaches.
In a recent randomized clinical trial, Mohajeri et al. found that pyloromyotomy or pylorus buginage could not reduce the incidence of DGE after esophagectomy with gastric pull-up [
24]. Moreover, there is evidence that patients who undergo pyloric drainage procedures may suffer from increased biliary reflux and dumping syndrome long term [
25,
26]. Wang et al. analyzed 368 patients following esophagectomy with esophageal substitute and found a greater incidence of both of these undesirable outcomes in patients who underwent pyloroplasty [
27].
The present study aimed to evaluate surgical outcomes following esophagectomy with gastric replacement with a special focus on gastric outlet obstruction in a large single-center series. In this series, clinical signs of DGE were observed in 16.5% of the cases, and pneumonia was observed in 27.1% of the cases, which is consistent with the current literature. Most authors report a DGE rate ranging around 15% [
28,
29], and most centers describe comparable rates of postoperative pneumonia [
4]. Since no pyloric drainage procedures were performed in the current study, we can conclude that these procedures are not necessary. Moreover, most of the patients with clinical signs of DGE were successfully treated with conservative therapy. Only a few patients required endoscopic balloon dilation (3.8%), and none of the patients with DGE required reoperation or underwent a so-called rescue pyloroplasty.
In the present series, postoperative endoscopy with exploration of the anastomosis was performed whenever a patient had any obvious clinical signs or unexplained increasing levels of inflammatory parameters in the blood, which explains the relatively high rate of postoperative endoscopies. The reason for this approach is based on our experience that in the case of an anastomotic leak, an early intervention, such as stenting or placement of an endoscopic vacuum sponge, is helpful to prevent a severe and prolonged postoperative course. Some of the patients with anastomotic leakage only showed small leaks without necrosis and mild clinical symptoms, which explains the low rate of re-operation for anastomotic leakage and the relatively low 30-day hospital morbidity of 2.9%.
There are limitations in the present study design. First, this was a single-center observational study without a control group. According to the department standard, none of the patients underwent pyloric drainage procedures. Therefore, the data can only be compared to the existing literature. Still, we believe that our data are clinically relevant since many recent studies refer to historical clinical data of patients who underwent surgery in the 1980s or 1990s. Since this time, not only the surgical procedure but also postoperative intensive care management, including mobilization and nutrition regimens, have changed tremendously.
It has been reported that pyloric drainage procedures are not only ineffective in preventing DGE but also can add relevant morbidity, such as esophageal leakage or stenosis, in the long-term follow-up. For example, Richardson et al. described a patient who developed late pyloroplasty leakage on postoperative day 16 following esophagectomy [
30]. Likewise, Antonoff et al. described two major complications directly related to pyloric drainage procedures, accounting for 0.6% of their study collective. One patient was re-explored on the first postoperative day because of bilious drainage from the midline abdominal incision due to a pinpoint hole at the pyloromyotomy. Another patient developed a leak at the pyloroplasty site and ultimately died following a complicated postoperative course [
25]. Zieren et al. reported one patient who died following insufficient pyloroplasty and another patient who developed a severe stricture secondary to surgical pyloric drainage, accounting for 3.8% of their study group [
31]. Although the overall surgical complication rate after pylorus drainage procedures seems to be relatively low, these practices are associated with significant morbidity and even mortality.
In more recent studies, the value of botulinum toxin injection in reducing gastric outlet obstruction was evaluated. In 2016, Fuchs et al. reported a trial in which 14 patients received botulinum toxin injections versus 27 who did not receive injections [
32]. In this study, the rate of postoperative pyloric dysfunction was found to be significantly lower in the botulinum toxin group. Moreover, patients who received botulinum toxin injections were discharged earlier (7.4 versus 10.7 days,
p < 0.05), and no differences were observed regarding anastomotic strictures or leaks. In contrast, Eldaif et al. found that patients receiving botulinum injections exhibited a higher rate of postoperative reflux symptoms and increased use of promotility agents and more frequently required postoperative endoscopic interventions. Therefore, the authors concluded that intrapyloric botulinum toxin injections should not be used as an alternative to standard drainage procedures [
33]. Consequently, the value of botulinum toxin injections as an alternative approach to reduce postoperative gastric outlet obstruction remains controversial. More randomized clinical studies with larger samples are required before this method can be generally recommended.
For postoperative DGE therapy, conservative approaches or endoscopic pyloric balloon dilation are safe and effective in most patients [
34‐
36]. For example, Maus et al. performed 89 pylorus balloon dilations after esophagectomy without complications. In this study, the total re-dilation rate for a 30-mm balloon was 20% [
37]. In rare cases of endoscopic therapy failures, rescue pyloroplasty has been described to be helpful and well tolerated. For example, Datta et al. reported that rescue pyloroplasty was successful in 9 of 13 cases (69%), leading to decreased rates of nausea, vomiting, bloating, prokinetic use, and total parenteral nutrition dependence [
38].