Does the Type of Intraoperative Pyloric Procedure During Minimally-Invasive Esophagectomy Predict the Need for Postoperative Endoscopic Interventions?

Danica Giugliano, MD, Adam C Berger, MD, Hanna Meidl, Michael J Pucci, MD, Ernest L Rosato, MD, Talar Tatarian, MD, Scott Keith, PhD, Nathaniel R Evans, MD, Francesco Palazzo, MD. Thomas Jefferson University Hospital

Introduction: The aim of this study was to compare intraoperative pyloric interventions and the rates of postoperative endoscopic interventions within the first six months following minimally invasive esophagectomy (MIE). Intraoperative pyloric procedures are commonly performed during esophagectomies to reduce the rate of postoperative gastric conduit dysfunction. These procedures include pyloroplasty (PP), pyloromyotomy (PM), and pyloric botox injections (BI). Despite these interventions, some patients experience postoperative symptoms of conduit dysfunction that warrant further endoscopic interventions.

Methods and Procedures: We queried our IRB-approved prospective foregut database to identify patients who underwent MIE (minimally-invasive 3-hole esophagectomy or minimally-invasive Ivor-Lewis esophagectomy) for esophageal carcinoma from January 2008 to January 2015 and who had six months of follow-up. Intraoperative pyloric procedure type was noted and the patients were grouped as “none”, “PP”, “PM” or “BI”. The types and rates of endoscopic interventions after surgery were reviewed and compared using pairwise comparisons. Significance was established at p<0.05.

Results: There were 146 patients who underwent a MIE for esophageal carcinoma. The majority (n=113, 76.9%) underwent a 3-hole MIE. Table 1 shows the types of pyloric procedures and types of endoscopic interventions. Postoperative endoscopic interventions were performed on a total of 38 patients (26.0%). Twenty-eight patients (19.2%) had anastomotic dilations and 16 patients (11.0%) had pyloric interventions (pyloric dilation and/or botox injection), with 6 of these patients requiring both anastomotic and pyloric interventions. The BI group was most likely to require any type of postoperative intervention (n=13, 31.7%) and was most likely to require a pyloric intervention (n=8, 19.5%). By contrast, the percentage of patients requiring pyloric intervention was 7.9% (n=3) for PM, 6.8% (n=4) for PP, and 12.5% (n=1) in the “none” group. Though not statistically significant, patients receiving intraoperative botox injections tended to require further pyloric interventions.

Conclusions: Which intraoperative pyloric intervention is the most effective during MIE remains unclear. Our data show that the patients who received botox injection to the pylorus demonstrated a trend toward requiring a higher number of secondary interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.

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