Does pyloroplasty following esophagectomy improve early clinical outcomes?

April 25, 2007

June 21, 2007

Omar A. Khan, James Manners, Arvind Rengarajan, Cardiothoracic Registrar (Department of Cardiothoracic Surgery, Southampton General Hospital, James Cook University Hospital, Middlesbrough, UK)

Joel Dunning, Department of Cardiothoracic Surgery, Southampton General Hospital, James Cook University Hospital, Middlesbrough, UK

In [patients undergoing esophagectomy] does a [pyloric drainage procedure] improve [early or late clinical outcomes].

You are performing an esophagectomy for a cT2N0M0 adenocarcinoma of the gastro esophageal junction. You have just mobilised the stomach and your surgical assistant asks whether you plan to perform to a pyloroplasty as he has heard it is associated with improved early post-operative recovery. You do not routinely do this but decide to check the literature after the operation.

Medline 1966 to November 2006 using the OVID interface.

[exp esophagectomy/ OR esophagectomy.mp or oesophagectomy.mp OR esophagus.mp OR oesophagus.mp OR retrosternal stomach.mp] AND [pyloroplasty.mp OR gastric drainage.mp OR pyloromyotomy.mp]

A total of 170 papers were identified. One meta-analysis was found that summarised 9 randomized controlled trials. This study together with the best 6 RCTs were selected

Although esophagectomy for cancer is a well-established operation, there exists much controversy as to the optimum surgical approach. With specific reference to routine pyloroplasty, advocates of this approach argue that this intervention prevents early gastric outlet obstruction associated with pyloric denervation, and hence reduces the risk of pulmonary aspiration. By contrast, it has been argued that pyloroplasty is unnecessary as gastric outlet obstruction is a rare occurrence following esophagectomy and that the procedure itself is associated with a number of complications.
Urschel et al performed a meta-analysis in 2002, finding 9 randomized controlled trials, that included 553 patients. They found non-significant trends towards a benefit of pyloroplasty for pulmonary morbidity (odds ratio 0.69 95%CI 0.42 to 1.14, p=0.15), pulmonary aspiration (odds ratio 0.25 95%CI 0.04 to 1.6, p=0.14), and a significant benefit for gastric outlet obstruction (odds ratio 0.18 95%CI 0.03 to 0.97, p=0.046). They also attempted to assess in a semi-quantitative fashion the results of later gastric symptoms reported by papers by assigning scores to outcomes described by the original papers. They found non significant trends towards quicker gastric emptying, food intake, and foregut obstructive symptoms. They concluded that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.
The Largest RCT was by Fok et al in 1991, where 200 patients undergoing Lewis-Tanner esophagectomy were randomized to pyloroplasty or control. 13 patients without drainage developed obstructive symptoms compared to none in the drainage group. In addition, significant benefits were shown for early and late symptoms with meals, although all other outcome measures showed only non-significant trends towards benefit.
Zieren et al randomized 107 patients to pyloroplasty or control but found no significant differences between the two groups. However the complications rate in this study was low in both groups.
Mannell et al performed a 40 patient RCT looking at gastric emptying, but again due to the low incidence of symptoms no significant differences were seen.
Chattopadhyay et al performed a small RCT to look a gastric emptying in 24 patients. Emptying was significantly delayed by more than 10 times in both groups post-operatively compared to pre-operatively, but the difference was significantly better in the pyloroplasty group. There were no other differences in either group.
Kobayashi et al performed a 67 patient randomized trial looking at gastric function 1 and 6 months post esophagectomy. The food ejection time was reduced in the pyloroplasty group but most other markers including nutritional evaluation, lymphocyte count, rapid turnover protein and body weight fluctuation were not significantly different.
Cheung et al performed a 72 patient randomized study looking at gastric emptying and late symptoms. They showed significantly quicker gastric emptying at 6 months, although symptoms did not correlate well with this improvement in transit time. They deemed that 2 patients in the control group could have benefited from pyloroplasty as the remainder were completely symptom free on follow up.

Pyloroplasty seems to reduce the incidence of gastric outlet obstruction and speed up gastric emptying. In addition the incidence of complications from this procedure seems low. However other significant improvements to outcomes such as mortality, nutrition, anastomotic leakage, gastric symptoms and aspiration are yet to be established.

1. Urschel JD, Blewett CJ, Young JE, Miller JD, Bennett WF.. Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials.
2. Fok M, Cheng SW, Wong J.. Pyloroplasty versus no drainage in gastric replacement of the esophagus.
3. Gupta S, Chattopadhyay TK, Gopinath PG, Kapoor VK, Sharma LK.. Emptying of the intrathoracic stomach with and without pyloroplasty.
4. Mannell A, McKnight A, Esser JD.. Role of pyloroplasty in the retrosternal stomach: results of a prospective, randomized, controlled trial.
5. Chattopadhyay TK, Shad SK, Kumar A.. Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy.
6. Zieren HU, Muller JM, Jacobi CA, Pichlmaier H.. Should a pyloroplasty be carried out in stomach transposition after subtotal esophagectomy with esophago-gastric anastomosis at the neck?
7. Kobayashi A, Ide H, Eguchi R, Nakamura T, Hayashi K, Hanyu F.. [The efficacy of pyloroplasty affecting to oral-intake quality of life using reconstruction with gastric tube post esophagectomy]. [Japanese].
8. Huang GJ, Zhang DC, Zhang DW.. A comparative study of resection of carcinoma of the esophagus with and without pyloroplasty.
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11. Chattopadhyay TK, Gupta S, Padhy AK, Kapoor VK.. Is pyloroplasty necessary following intrathoracic transposition of stomach? Results of a prospective clinical study.
12. Cheung HC, Siu KF, Wong J.. Is pyloroplasty necessary in esophageal replacement by stomach?