The denervated stomach as an esophageal substitute is a contractile organ

Combined endoscopic stenting and laparoscopic stent fixation for benign gastric tube stricture after esophagectomy: a case report

BACKGROUND

There are several options for the treatment of gastrointestinal stricture, including endoscopic stent placement and bypass surgery. However, a benign stricture is difficult to manage in a reconstructed gastric tube in the thoracic cavity owing to the technical difficulty of bypass surgery, and the possibility of stent migration.

CASE PRESENTATION

A 78-year-old woman was admitted to our hospital for treatment for her inability to eat. She had undergone video-assisted subtotal esophagectomy with retromediastinal gastric tube reconstruction 7 years earlier. At the current admission, there was a severely dilated gastric tube in the thoracic cavity with a soft stricture immediately anterior to the spine. Conservative therapy was ineffective; therefore, endoscopic stenting was performed. However, the stent migrated to the upper side of the stricture because the stricture was mild, and the stent was not fixed in the gastric tube. Next, endoscopic stent placement followed by laparoscopic stent fixation was performed. The stent was patent and worked well, and the patient's body weight increased. However, the stent collapsed 2 years later, with recurrence of symptoms. Stent-in-stent placement with an over-the-scope clip was performed, and the second stent was also patent and worked well.

CONCLUSIONS

Laparoscopic stent fixation with endoscopic stent placement could be an effective option for patients with a benign stricture in the reconstructed gastric tube.

Gastro-Intestinal Disorders and Micronutrient Deficiencies following Oncologic Esophagectomy and Gastrectomy

Primary surgical indications for the esophagus and stomach mainly involve cancer surgeries. In recent years, significant progress has been made in the field of esogastric surgery, driven by advancements in surgical techniques and improvements in perioperative care. The rate of resectability has increased, and surgical strategies have evolved to encompass a broader patient population. However, despite a reduction in postoperative mortality and morbidity, malnutrition remains a significant challenge after surgery, leading to weight loss, muscle mass reduction, and deficiencies in essential nutrients due to digestive complications. Malnutrition worsens quality of life and increases the risk of tumor recurrence, significantly affecting prognosis. Nevertheless, the nutritional consequences following surgery are frequently overlooked, mainly due to a lack of awareness regarding their long-term effects on patients who have undergone digestive surgery, extending beyond six months. Micronutrient deficiencies are frequently observed following both partial and total gastrectomy, as anticipated. Surprisingly, these deficiencies appear to be similarly prevalent in patients who have undergone esophagectomy with iron, vitamins A, B1, B12, D, and E deficiencies commonly observed in up to 78.3% of the patients. Recognizing the distinct consequences associated with each type of intervention underscores the importance of implementing preventive measures, early detection, and prompt management.

PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy: study protocol for the PYNI-GAREREO phase III randomized controlled trial

BACKGROUND

After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying.

METHODS

The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively.

DISCUSSION

We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346 .

Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis

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.

There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy

INTRODUCTION

Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE.

PATIENTS AND METHODS

816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus.

RESULTS

27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL.

CONCLUSION

Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

Functional syndromes and symptom-orientated aftercare after esophagectomy

BACKGROUND

Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life.

PURPOSE

The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare.

CONCLUSIONS

Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.

Endoscopic pyloromyotomy in minimally invasive esophagectomy: a novel approach

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.

Gastrointestinal side effects of upper gastrointestinal cancer surgery

In this chapter, we describe the gastrointestinal side effects of oesophagectomy, gastrectomy and pancreaticoduodenectomy for cancer, with a focus on long-term functional impairments and their management. Improvements in upper gastrointestinal cancer surgery have led to a growing group of long-term survivors. The invasive nature of these surgeries profoundly alters the upper gastrointestinal anatomy, with lasting implications for long-term function, and how these impairments may be treated. Successfully maintaining a high quality of survivorship requires multidisciplinary approach, with survivorship care plans focused on function as much as the detection of recurrence.

Effect of Pyloroplasty on Gastric Conduit Emptying and Patients' Quality of Life After Ivor Lewis Esophagectomy

Background: Delayed gastric emptying (DGE) is a common complication after esophagectomy with gastric tube reconstruction. It is still unclear whether a pyloric drainage procedure might reduce the risk of DGE. Methods: We identified in our database all patients subjected to Ivor Lewis esophagectomy after neoadjuvant chemoradiotherapy in the period 2000-2012. In the period 2000-2009, we performed a routine pyloroplasty (pyloroplasty group, PP group, 15 patients), after 2009 we did not perform any type of pyloric drainage procedure (nonpyloroplasty group, NPP group, 11 patients). We compared the groups with subjective questionnaires to assess the perceived quality of life (QoL) (QLQ-C30 and OES-18) and with objective test to study the gastric tube emptying (timed barium swallow test, scintigraphy, 24 hours' pH-metry). Results: No difference was observed in questionnaires QLC-C30 and OES-18 scores: 73% of patients in PP group and 63% in NPP group scored their overall QoL as good to excellent (QLC-C30). We did not report difference in timed barium swallow test results and in scintigraphy results. Twenty-four-hour pH-metry results showed in PP group a nonsignificant higher number of acid reflux episodes (NPP group 23.2 ± 9.5 versus PP group 41.3 ± 10.7, P = .29) and a longer time with pH <4 (NPP group 0.89% ± 1.6% versus PP group 3.1% ± 2.1%, P = .24). Conclusions: In our series, pyloroplasty was not associated with improved long-term QoL nor with better gastric conduit emptying. Further studies are needed to confirm these findings.

The Optimal Pyloric Procedure: A Collective Review

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.

Delayed Gastric Emptying after Esophagectomy: Management and Prevention

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.

Pyloric distensibility measurement after gastric surgery: Which surgeries are associated with pylorospasm?

BACKGROUND AND STUDY AIMS

History of gastric surgery is found in 10% of patients with gastroparesis, and vagal lesion is often suspected to be the cause of pylorospasm. Recently, pyloric distensibility measurement using the EndoFLIP^® system showed that pylorospasm was present in 30%-50% of gastroparetic patients. Our objective was to assess whether pylorospasm, diagnosed using EndoFLIP^® system was observed in three different types of gastric surgeries: antireflux surgery, sleeve gastrectomy, and esophagectomy.

PATIENTS AND METHODS

Pyloric distensibility and pressure were measured using the EndoFLIP^® system in 43 patients from two centers (18 antireflux surgery, 16 sleeve gastrectomy, and nine esophagectomy) with dyspeptic symptoms after gastric surgery, and in 21 healthy volunteers. Altered pyloric distensibility was defined as distensibility below 10 mm² /mm Hg as previously reported.

RESULTS

Compared to healthy volunteers (distensibility: 25.2 ± 2.4 mm² /mm Hg; pressure: 9.7 ± 4.4 mm Hg), pyloric distensibility was decreased in 61.1% of patients in the antireflux surgery group (14.5 ± 3.4 mm² /mm Hg; P < .01) and 75.0% of patients in the esophagectomy group (10.8 ± 2.1 mm² /mm Hg; P < .05), while pyloric pressure was only increased in the antireflux surgery group (18.9 ± 2.2 mm Hg; P < .01). Pyloric distensibility and pressure were similar in healthy volunteers and in sleeve gastrectomy (distensibility: 20.3 ± 3.8 mm² /mm Hg; pressure: 15.8 ± 1.6 mm Hg) groups, with decreased pyloric distensibility affecting 18.7% of sleeve gastrectomy patients.

CONCLUSION

Antireflux surgery and esophagectomy were associated with pylorospasm although pylorospasm was not found in all patients. Sleeve gastrectomy was not associated with altered pyloric distensibility nor altered pyloric pressure.

Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process

Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.

Preoperative endoscopic pyloric balloon dilatation decreases the rate of delayed gastric emptying after Ivor-Lewis esophagectomy

Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p = 0.014), respectively. DGE-related complications such as anastomotic leaks (p = 0.466), pulmonary complications (p = 0.466) and longer median hospital stay (p = 0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.

Delayed emptying of the gastric conduit after esophagectomy

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.

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children

PURPOSE

Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients.

METHODS

Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement.

RESULTS

Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8-5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9-4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p<0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing.

CONCLUSION

The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

Management of gastric conduit retention following hybrid and minimally invasive esophagectomy for esophageal cancer: Two retrospective case series

INTRODUCTION

Following esophagectomy about 5% of patients experience long-term gastric conduit retention. We report two patients with surgical correction for this problematic condition. This case series is a retrospective, non-consecutive single center report.

PRESENTATION OF CASES

A slender female aged 76 (patient 1) and an obese man aged 69 (patient 2) with esophageal cancer, underwent hybrid and total minimally invasive Ivor-Lewis esophagectomy, respectively. The conduit was tubularized, and the stapled anastomosis located above carina. The crura were divided in patient 1. Contrast enema revealed a straight (patient 1) or redundant (patient 2) thoracic conduit. Conduit retention in patient 1 began after 47 months. After 61 months reoperation was performed with open thoracoabdominal access for mobilization, abdominal reduction and diaphragmatic suture fixation of the herniated conduit. Symptoms improved and oral nutrition is still sufficient after 8 months.Patient 2 had clinically significant retention after 15 months, despite using pyloric Botox injection and expandable metal stenting. At laparoscopic reoperation after 27 months a partial conduit mobilization and refixation were unsuccessful, but an accidental colonic hiatal hernia was taken down. After 28 months a second reoperation was performed, similar to patient 1. Fifteen months afterwards the patient still ate sufficiently, but a limited double reherniation had occurred.

DISCUSSION

Long-term retention post-esophagectomy often start with an initial redundant conduit, that can increase from food-induced stretching and declive emptying against gravity. A wide hiatal opening probably also predispose to conduital herniation.

CONCLUSIONS

Conduit retention improved after mobilization, reduction and its hiatal fixation. A too wide or narrow hiatal opening must be avoided to prevent herniation.

Gastric Outlet Obstruction After Esophagectomy: Retrospective Analysis of the Effectiveness and Safety of Postoperative Endoscopic Pyloric Dilatation

BACKGROUND AND AIMS

Delayed gastric emptying after esophagectomy with gastric replacement can pose a significant postoperative problem, often leading to aspiration and pneumonia. The present study analyzes retrospectively the effectiveness of endoscopic pyloric dilatation for post-surgical gastric outlet obstruction.

METHODS

Between March 2006 and March 2010, 403 patients underwent a transthoracic en-bloc esophagectomy and reconstruction with a gastric tube and intrathoracic esophagogastrostomy. In patients with postoperative symptoms of an outlet dysfunction and the confirmation by endoscopy, pyloric dilatations were performed without preference with either 20- or 30-mm balloons.

RESULTS

A total of 89 balloon dilatations of the pylorus after esophagectomy were performed in 60 (15.6 %) patients. In 21 (35 %) patients, a second dilatation of the pylorus was performed. 55 (61.8 %) dilatations were performed with a 30-mm balloon and 34 (38.2 %) with a 20-mm balloon. The total redilatation rate for the 30-mm balloon was 20 % (n = 11) and 52.9 % (n = 18) for the 20-mm balloon (p < 0.001). All dilatations were performed without any complications.

CONCLUSIONS

Pylorus spasm contributes to delayed gastric emptying leading to postoperative complications after esophagectomy. Endoscopic pyloric dilatation after esophagectomy is a safe procedure for treatment of gastric outlet obstruction. The use of a 30-mm balloon has the same safety profile but a 2.5 lower redilatation rate compared to the 20-mm balloon. Thus, the use of 20-mm balloons has been abandoned in our clinic.

Risk factors for delayed gastric emptying after esophagectomy

PURPOSE

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy with gastric tube reconstruction. Little is known about risk factors that can predict this debilitating complication.

METHODS

Patients who underwent elective esophagectomy from 2008 to 2016 in a single center were retrospectively reviewed. Diagnosis of DGE was based on clinical, radiological, and endoscopic findings. Uni- and multivariate analyses were performed to identify patient-, tumor-, and procedure-related factors that increase the risk of DGE.

RESULTS

One hundred eighty-two patients were included. Incidence of DGE was 39.0%. Overall, 27 (14.8%) needed an endoscopic intervention. Patients in the DGE group had a longer hospital stay (p < 0.01). No differences were found for the 30-day (p = 1.0) and hospital mortality (p = 1.0). On univariate analyses, a significant influence on DGE was demonstrated for pre-existing pulmonary comorbidity (p = 0.04), an anastomotic leak (p < 0.01), and postoperative pulmonary complications (pneumonia: p = 0.02, pleural empyema: p < 0.01, and adult respiratory distress syndrome: p = 0.03). Furthermore, there was a non-significant trend toward an increased risk for DGE for the following variable: female gender (p = 0.09) and longer operative time (p = 0.09). On multivariate analysis, only female gender (p = 0.03) and anastomotic leak (p = 0.01) were significantly associated with an increased risk for DGE.

CONCLUSIONS

DGE is a frequent complication following esophagectomy that can successfully be managed with conservative or endoscopic measures. DGE did not increase mortality but was associated with increased morbidity and prolonged hospitalization. We identified risk factors that increase the incidence of DGE. However, this has to be confirmed in future studies with standardized definition of DGE.

Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage

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.

Validation of the paracetamol absorption test for measuring gastric tube emptying in esophagectomized patients versus gold standard scintigraphy

OBJECTIVE

Scintigraphy is the gold standard for objective measurement of delayed gastric tube emptying after esophagectomy. The aim of this pilot study is to validate, by reference to scintigraphy, the paracetamol absorption test for measuring gastric tube emptying in esophagectomized patients.

MATERIAL AND METHODS

The paracetamol absorption test and scintigraphy were performed simultaneously in 13 patients who had undergone an esophagectomy with gastric tube reconstruction. Emptying was calculated for both methods and compared. Post-esophagectomy symptoms and quality of life (QoL) were assessed by European Organization on Research and Treatment of Cancer questionnaires.

RESULTS

Mean time to 50% emptying was 17 min measured with the paracetamol absorption test and 23 min with scintigraphy. For time to 25% emptying, Bland-Altman calculation gave a bias of 1.6 min and 95% limits of agreement (LoA) of -6.3 to 9.5 min. For time to 50% emptying, there was one outlier resulting in a bias of -6.33 min and 95% LoA of -36.4 to 23.8 min. For time to 75% emptying, bias was -11.6 min and 95% LoA of -38.5 to 15.4 min. Post-esophagectomy symptoms were similar to those reported previously, and QoL was comparable to the general Swedish population.

CONCLUSIONS

There was reasonably close correlation between the paracetamol absorption test and scintigraphy for time to 25% and 50% emptying, except for one outlier. For time to 75% emptying the methods were in less accordance. The results indicate that the paracetamol absorption test may be a useful screening tool for identifying delayed gastric tube emptying in this patient group.

Thoracoscopic Implant of Neurostimulator for Delayed Gastric Conduit Emptying After Esophagectomy

BACKGROUND AND AIMS

Gastroparesis is a clinical syndrome characterized by delayed gastric emptying in the absence of mechanical outlet obstruction. Use of the denervated stomach as an esophageal substitute is a common cause of transient gastroparesis. Gastric electrostimulation through a thoracotomy approach has previously been reported to be effective in patients with medically refractory postesophagectomy gastroparesis. We report the first thoracoscopic implant of a gastric neurostimulator.

METHODS AND RESULTS

A 57-year-old woman underwent Ivor Lewis esophagectomy for early stage (T1N0) adenocarcinoma in 2007. She progressively developed progressive dysphagia, regurgitation, and a 29-kg weight loss. The barium swallow study and upper gastrointestinal endoscopy showed a dilated intrathoracic stomach without evidence of mechanical obstruction. Erythromycin and multiple endoscopic dilatations of the pylorus were unsuccessful, and eventually, a feeding jejunostomy was performed. At the time the patient was referred to our outpatient clinic, she was unable to eat and depended on total enteral nutrition. Computed tomography, endoscopy, and barium swallow study confirmed that there was no evidence of recurrent adenocarcinoma or mechanical gastric outlet obstruction. A gastric electrostimulator system (Enterra(®)) was implanted through a right thoracoscopic access and connected to the gastric conduit. At 6-month follow-up, there was a significant improvement of the total symptom score and quality of life.

CONCLUSIONS

Electrostimulation of the gastric conduit after esophagectomy can safely be performed through a thoracoscopic approach and may represent a reasonable therapeutic option in patients with symptomatic and medically refractory delayed gastric emptying.

Surgical techniques to prevent delayed gastric emptying after esophagectomy with gastric interposition: a systematic review

Delayed gastric emptying is observed in 10% to 50% of patients after esophagectomy with gastric interposition. The effects of gastric interposition diameter, pyloric drainage, reconstructive route, and anastomotic site on postoperative gastric emptying were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Most studies showed superior passage of the gastric tube compared with the whole stomach. Pyloric drainage is not significantly associated with the risk of developing delayed gastric emptying after esophagectomy. For reconstructive route and anastomotic site, available evidence on delayed gastric emptying is limited. Prospectively randomized studies with standardized outcome measurements are recommended.

Should we continue to drain the pylorus in patients undergoing an esophagectomy?

A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy with gastric conduit reconstruction. Earlier data recommend performing a pyloric drainage procedure for all esophagectomies; however, recent studies have questioned this. A thorough literature search (January 2001-November 2011) was performed using the terms esophagectomy, pyloroplasty, pyloromyotomy, botulinum toxin, and pyloric drainage. Only studies that compared patient outcome after undergoing an esophagectomy with a pyloric drainage procedure with those undergoing an esophagectomy without a pyloric drainage procedure were selected. Only four studies, comprising 668 patients in total, were identified that compared patient outcome after undergoing an esophagectomy with or without a pyloric drainage procedure, and two additional meta-analyses were identified and selected for discussion. All studies were retrospective, and because of the heterogeneity of studies, patient demographics, reporting, and statistical analysis of patient outcome, pooling of data and meta-analysis could not be performed. Careful analysis demonstrated that pyloric drainage procedure was associated with a non-significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was determined between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity. While there are risks associated with a pyloric drainage procedure and data exist supporting its omission during an esophagectomy, no good conclusion can be drawn from the current literature. Larger multi-institutional, prospective studies are required to definitively answer this question.

Comparison of pyloric intervention strategies at the time of esophagectomy: is more better?

BACKGROUND

Controversy remains regarding the role of pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. We aimed to compare the effect of pyloric drainage strategies upon subsequent risk of complications suggestive of conduit distention, including aspiration and anastomotic leak.

METHODS

A retrospective study was conducted reviewing patients undergoing esophagectomy between January 2007 and April 2012. Prospectively collected data included baseline comorbidities, operative details, hospital course, and complications. Statistical comparisons were performed using analysis of variance for continuous variables and χ(2) testing for categorical variables.

RESULTS

There were 361 esophagectomies performed during the study period; 68 were excluded from analysis (for prior esophagogastric surgery or benign disease or both). Among 293 esophagectomies included, emptying procedures were performed as follows: 44 (15%), no drainage procedure; 197 (67%), pyloromyotomy/pyloroplasty; 8 (3%), dilation alone; 44 (15%), dilation plus onabotulinumtoxinA. Aspiration occurred more frequently when no pyloric intervention was performed (5 of 44 [11.4%] versus 6 of 249 [2.4%], p = 0.030). The incidences of anastomotic leak (18 [6.1%]) and gastric outlet obstruction (5 [1.7%]) were statistically similar among groups. Subgroup analysis demonstrated persistence of these findings when limiting the comparison to transthoracic esophagectomies. Major complications directly related to pyloroplasty/pyloromyotomy occurred in 2 patients (0.6%), including 1 death (0.3%).

CONCLUSIONS

These data suggest that omission of pyloric intervention at the index operation results in more frequent aspiration events. The combination of dilation plus onabotulinumtoxinA provided for a similar complication profile compared with surgical drainage. Future prospective comparisons are needed to evaluate these short-term effects of pyloric intervention as well as long-term sequelae such as dumping syndrome and bile reflux.

Delayed gastric emptying after esophagectomy for malignancy

BACKGROUND

Controversy still exists about the need for pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. Although pyloric drainage may prevent postoperative delayed gastric emptying (DGE), it may also promote dumping syndrome and bile reflux. The aims of this study were to audit the incidence and management of DGE in patients without routine pyloric drainage after esophagectomy in a university medical center.

PATIENTS AND METHODS

From July 2006 to June 2012, data from 356 consecutive patients who underwent esophagectomy with a gastric conduit without pyloric drainage for esophageal or gastric cardia carcinoma were reviewed. Major observation parameters were the incidence, management, and outcomes of DGE.

RESULTS

Overall incidence of DGE was 15.7% (56 of 356). Early DGE developed in 26 patients, and late DGE developed in 30 patients. There were no differences in demographic and intraoperative data between the two groups with or without DGE. More DGE was documented in patients with an intra-right thoracic gastric conduit (P=.031). A higher incidence of postoperative pneumonia was observed in patients exhibiting early DGE, but without significance (P=.254). There were also no significant impacts on respiratory failure (P=.848) and anastomotic leakage (P=.257). There was an increased postoperative hospital stay with DGE, but without significance (P=.089). Endoscopic balloon dilatation of the pylorus was used to manage 33.9% of patients with DGE, yielding a 78.9% (15 of 19) success rate without complications. In 3 patients endoscopy showed the pylorus was open, and their symptoms improved over time. One patient with tumor-related DGE was treated by pyloric stent. The remaining patients were adequately treated with conservative management.

CONCLUSIONS

Omitting the operative drainage procedure does not lead to an increased frequency of DGE after esophagectomy with a gastric conduit. Many patients responded to conservative management, and endoscopic balloon pyloric dilatation can be effective in managing the DGE postoperatively.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.

Usefulness of Pyloromyotomy With Transhiatal Esophagectomy in Improving Gastric Emptying

INTRODUCTION

Pyloromyotomy is a pyloric drainage procedure routinely done during transhiatal esophagectomy (THE) to prevent delayed gastric emptying (GE) resulting from truncal vagotomy. However, controversy still surrounds the need for pyloric drainage following esophageal substitution with gastric conduit after esophagectomy. The aim of this study was to determine the usefulness of pyloromyotomy in improving the postoperative gastric emptying time.

METHODS

Forty patients with esophageal cancer underwent THE. 20 patients underwent THE without pyloromyotomy (group A), while the other 20 patients (group B) underwent THE with pyloromyotomy. Using Technetium-99 m, gastric scintigraphy-using gamma camera, was done for all the patients 6 months post-surgery to measure the gastric half emptying time (T50).

RESULTS

For the liquid phase, the mean (T50) in the patients without pyloromytomy (group A) was 74.5 ± 56.71 minutes ± SD versus 62.85 ± 59.35 minutes ± SD in the patients with pyloromytomy (group B) which is not significant (P = 0.529). For the solid phase, the mean (T50) in patients of group A was 139.40 ± 94.156 minutes ± SD versus 141.15 ± 48.423 minutes ± SD in group B (P value 0.941) which is also not significant.

CONCLUSION

Six months after THE, pyloromyotomy done with THE showed no significant value on affecting the mean gastric emptying time compared to those underwent THE without pyloromyotomy.

Gastric tube perforation after esophagectomy for esophageal cancer

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.

Prevention of early delayed gastric emptying after high-level esophagogastrostomy by "pyloric digital fracture"

OBJECTIVE

This study was designed to evaluate the clinical efficacy of pyloric digital fracture for the prevention of early delayed gastric emptying (DGE) after high-level esophagogastrostomy.

METHODS

From January 2004 to March 2009, we sequentially enrolled 78 patients after esophagogastrostomy: 48 patients with pyloric digital fracture (DF group) and 30 patients without any drainage procedure (non-DF group). Intraoperative manometric study was performed in 48 patients of the DF group. Postoperative evaluation was performed, including symptomatic questionnaire, radiographic study, and gastric scintigraphy.

RESULTS

Intraoperative manometric study revealed that basal pyloric pressure and peak pressure of pylorus in phase III of the migrating motor complex increased significantly after gastric conduit was made and anastomosed, but decreased appreciably following digital fracture. Compared with the peak pressure of IPPW before digital fracture (88.52 ± 19.88 mmHg), it appreciably decreased following digital fracture (40.45 ± 13.52 mmHg). Occurrences of IPPW (in 10 min) and duration time of each occurrence (s) had similar trends for before and after digital fracture (11.5 ± 4.5 vs. 5.0 ± 3.5 and 7.0 ± 2.0 vs. 3.0 ± 1.0, respectively). Postoperative evaluation demonstrated that early DGE occurred in four patients in the non-DF group (13.3%), and there was no DGE patient in the DF group. There was significant difference regarding gastric scores between the DF group and the non-DF group (10.5 ± 3.4 vs. 16.7 ± 3.8, t = 2.8271, P < 0.05). Gastric scintigraphy revealed that either semi-emptying-time or percent of retention at 4 h of the DF group was significantly lower than that of the non-DF group.

CONCLUSION

Pyloric digital fracture can prevent early DGE after high-level esophagogastrostomy efficaciously and conveniently.

Does the use of nizatidine, as a pro-kinetic agent, improve gastric emptying in patients post-oesophagectomy?

PURPOSE

Delayed gastric emptying following oesophagectomy is common and can often lead to weight loss, malnutrition and a poor quality of life. Animal models have shown that nizatidine, a histamine H2-receptor antagonist, has pro-kinetic properties and can accelerate gastric emptying. Patients post-oesophagectomy require long-term acid suppression medication; if nizatidine can improve gastric emptying, it can be adopted for its dual pharmacological actions.

METHODOLOGY

Twenty consecutive patients were prospectively enrolled in this trial following oesophagectomy. All patients were more than 6 months post-surgery and had no evidence of recurrent cancer. A baseline nuclear medicine scan following a radiolabelled meal was conducted and then repeated after 1 week of nizatidine (150 mg bd) treatment. Quality of life and eating comfort data were collected.

RESULTS

Oesophagectomy causes a significant delay in gastric emptying. Early satiety (80%) and reflux (65%) were the most common post-operative complaints. The percentage of food remaining in the stomach at 60 min post-meal was significantly more than normal values in both the pre- and post-nizatidine studies. There is no advantage in using nizatidine as a pro-kinetic agent.

CONCLUSIONS

Impaired gastric emptying post-surgery causes a change in eating habits. Patients in this study did not lose a significant amount of weight despite all indicating worse eating comfort. Patients required more regular meals or snacks throughout the day and avoid foods that are difficult to swallow. It is likely that gastric motility only plays a small role in the emptying process and gravity combined with appropriate drainage procedures (pyloroplasty/pyloromyotomy) at the time of surgery are more important.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.

Peptic ulcer of the gastric tube after esophagectomy for cancer: clinical implications

The use of the stomach as an esophageal substitute has become a well-established treatment procedure after esophagectomy for cancer. During the procedure, a bilateral truncal vagotomy is performed, which should prevent the occurrence of acid-related diseases in the gastric tube and in the remaining esophagus. We report the case of a man who presented a plugged perforated peptic ulcer that subsequently decompensated following endoscopic examination 1 year after a transthoracic esophagectomy with neoadjuvant chemo-radiation for a middle third squamous cell carcinoma. Resection of the ulcer and suture with a pleural patch was performed. There was no evidence of recurrent malignancy at time of surgery. The pathophysiology of gastric tube ulcer is multifactorial. Long-term treatment with an anti-secretory proton pump inhibitor may decrease esophageal complications of duodeno-gastric-esophageal reflux and could prevent the recurrence of gastric tube ulcers.

Gastrointestinal motility after digestive surgery

Gastrointestinal (GI) motility dysfunction is a common complication of any abdominal surgical procedure. During fasting, the upper GI tract undergoes a cyclic change in motor activity, called the interdigestive migrating motor contraction (IMC). The IMC is divided into four phases, with phase III having the most characteristic activity. After digestive surgery, GI motility dysfunction shows a lack of a fed response, less phase II activity, more frequent phase III activity of the IMC, and some phase III activity migrating orally. Postoperative symptoms have been related to motor disturbances, such as interrupted or retrograde phase III or low postprandial activity. The causes of GI disorder are autonomic nervous dysfunction and GI hormone disruptions. The administration of a motilin agonist can induce earlier phase III contractions in the stomach after pancreatoduodenectomy. For nervous dysfunction, an inhibitory sympathetic reflux is likely to be important in postoperative motility disorders. Until recently, treatment for gut dysmotility has consisted of nasogastric suction, intravenous fluids, and observation; however, more effective treatment methods are being reported. Recent discoveries have the potential to decrease postoperative gut dysmotility remarkably after surgery.

Trans-cutaneous electrogastrographic study of gastric myoelectric activity in transposed intrathoracic stomach after esophagectomy

We examined the feasibility of trans-cutaneous electrogastrography (EGG) in recording myoelectric activity of the transposed thoracic stomach after esophagectomy. Nineteen patients who had Ivor-Lewis esophagectomy were studied. The EGG signal was recorded using cutaneous electrodes placed over the lower sternum. Eleven patients who underwent total gastrectomy served as controls. Normal rhythm pattern (2.4-3.6 cpm > or = 70%) and power ratio (PR > or = 2) was observed in five and 12 patients, respectively, after esophagectomy. The observation of normal gastric rhythm was more frequent in the postprandial period in the esophagectomy group (median 42.6%vs. 7.4%, P = 0.01), and the PR was significantly higher (median 2.27 vs. 1.38, P = 0.013) than the gastrectomy group. Feeding further increased the prevalence of normal gastric slow wave in the esophagectomy group (median 14.8% to 42.6%, P = 0.002) and improved the stability of dominant frequency (median 78% to 67%, P = 0.015). We conclude that gastric myoelectric activities of thoracic transposed stomach can be detected from cutaneous sternal electrodes. This represented a preservation of gastric motility even when the stomach is pulled up to the thorax as a substitute for the esophagus.

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

BACKGROUND AND AIMS

Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy.

MATERIALS AND METHODS

One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed.

RESULTS

Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis.

CONCLUSION

Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.

Intrathoracic Gastric Emptying of Solid Food After Esophagectomy for Esophageal Cancer

BACKGROUND

Information on the function of the intrathoracic stomach after esophageal resection for esophageal cancer is limited. This study evaluated the factors affecting intrathoracic gastric emptying of solid food in patients who had undergone this surgery.

METHODS

Between February 2003 and August 2003, intrathoracic gastric emptying of solid food was evaluated by radioisotope in 56 of the patients who underwent esophageal replacement surgery with the stomach for esophageal cancer. The 50% gastric emptying time was categorized into three ranges: over 180 minutes was defined as delayed, within 180 minutes as intermediate, and when all the radioisotopes were dumped into the jejunum as rapid. The factors affecting the gastric emptying were analyzed.

RESULTS

In 6 out of 56 (10.7%) patients the radioisotope removal was too rapid to check the gastric-emptying time, and hence the analysis was performed in 50 patients. Twenty-one (37.5%) patients showed significantly delayed gastric emptying. The 50% gastric emptying time calculated by an exponential fitting method was 422 and 109 minutes in the delayed and intermediate groups, respectively. Age, the method of gastric drainage, and the stomach shape used did not affect the intrathoracic gastric emptying. Only the follow-up interval after surgery was a significant factor on gastric emptying (p = 0.024). The intrathoracic gastric emptying of solid food was more and more increased over time after surgery by regression analysis (p = 0.03).

CONCLUSIONS

The use of the intrathoracic stomach as an esophageal substitute had a significant effect on gastric emptying, with intrathoracic gastric emptying of solid foods immediately after esophagectomy being markedly prolonged in about 50% of patients. However, the intrathoracic gastric emptying significantly increased over time. Research is required into improving intrathoracic gastric emptying in the early period after esophagectomy.

Motor and electrogastrographic activity of the gastric tube formed after esophagectomy

In order to characterize the motor activity of a surgically constructed gastric tube, several hours of ambulatory intraluminal pressure recordings were performed in 6 patients following esophagectomy and gastric tube construction. Whole pressure waves were spectrally analyzed by Fast Fourier Transform (FFT). Simultaneous abdominal and thoracic electrogastrograms (EGGs) were recorded for about 20 min both before and after meals during ambulatory pressure recording. The pressure waves and EGGs for each 20 min recording were analyzed by the maximal entropy method (MEM). While the motility index of the pressure waves decreased after a meal, the 3 cpm component of these waves (2.4-3.7 cpm) increased significantly (n=6, P<0.05). Both bradygastria (0-2.4 cpm) and the duodeno-respiratory component (10-15 cpm) decreased, while the tachygastria component (3.7-10 cpm) increased, although these differences were not significant. The peak power of the gastric tube abdominal EGGs was significantly larger than that of control abdominal or thoracic EGGs in each of the 1 cpm (0-2.4 cpm), 6 cpm (5.0-7.4) and 8 cpm components (7.5-9.9). The thoracic EGG consisted mainly of the 3 cpm component, while the spectral amplitudes of the 1, 6, 8 and 10 cpm components were below 6% of the 3 cpm component. The peak spectral frequency both of the intraluminal pressure waves by FFT and of the thoracic EGGs by MEM occurred within the 3 cpm component. A cross correlation of about 0.2-0.3 occurred between the thoracic EGGs and the intraluminal pressure waves. Thus the gastric tube seems to preserve most of the original gastric motor characteristics and to contribute as a substitute for the original esophagus and stomach.

Synchronous electrogastrographic and manometric study of the stomach as an esophageal substitute

AIM

To investigate the electric and contractile mechanisms involved in the deranged function of the transposed stomach in relation to the course of the symptoms and the changes in contractile and electrical parameters over time.

METHODS

Twenty-one patients after subtotal esophagectomy and 18 healthy volunteers were studied. Complaints were compiled by using a questionnaire, and a symptom score was formed. Synchronous electrogastrography and gastric manometry were performed in the fasting state and postprandially.

RESULTS

Eight of the operated patients were symptom-free and 13 had symptoms. The durations of the postoperative periods for the symptomatic (9.1+/-6.5 mo) and the asymptomatic (28.3+/-8.8 mo) patients were significantly different. The symptom score correlated negatively with the time that had elapsed since the operation. The percentages of the dominant frequency in the normogastric, bradygastric and tachygastric ranges differed significantly between the controls and the patients. A significant difference was detected between the power ratio of the controls and that of the patients. The occurrence of tachygastria in the symptomatic and the symptom-free patients correlated negatively both with the time that had elapsed and with the symptom score. There was a significant increase in motility index after feeding in the controls, but not in the patients. The contractile activity of the stomach increased both in the controls and in the symptom-free patients. In contrast, in the group of symptomatic patients, the contractile activity decreased postprandially as compared with the fasting state.

CONCLUSION

The patients' post-operative complaints and symptoms change during the post-operative period and correlate with the parameters of the myoelectric and contractile activities of the stomach. Tachygastria seems to be the major pathogenetic factor involved in the contractile dysfunction.

Laparoscopic esophagectomy in the palliative treatment of advanced esophageal cancer after radiochemotherapy

BACKGROUND

Esophageal cancer is associated with a poor long-term prognosis. Only a 10% 5-year survival rate is reported. This article aims to evaluate the feasibility and efficacy of laparoscopic esophagectomy for the palliative treatment of advanced esophageal cancer (T3-T4 Nx-N1) after neoadjuvant therapy.

METHODS

From March 1998 to July 2002, 35 patients (mean age, 64.6 years; range, 35-72 years) affected by advanced cancer of the middle lower third of the esophagus came to the authors' observation. All received neoadjuvant radiochemotherapy. Of the 35 patients, 22 (62.9%) showed a positive response to treatment (>or=50% reduction of maximal cross-sectional area of the tumor), and surgical intervention was performed 4 weeks after the end of the therapy. The operations were accomplished through the laparoscopic approach and left lateral cervicotomy.

RESULTS

The mean operative time was 160 min (range, 120-260 min). One patient (4.5%) experienced a cervical anastomotic leak. Three patients (13.6%) died in the postoperative period: one of myocardial infarction and two of acute respiratory failure. The mean postoperative hospital stay was 12.1 days (range, 9-23 days). After a mean follow-up period of 20.2 months (range, 10-40 months), 13 patients (68.4%) were alive.

CONCLUSIONS

The laparoscopic approach seems to be effective for the palliative treatment of advanced esophageal cancer. Further trials will be necessary to evaluate the advantages of this technique.

Manometric evaluation of the intrathoracic stomach after gastric transposition in children

Gastric transposition (GT) is one of the options for the esophageal replacement in children with esophageal atresia with or without tracheoesophageal fistula (EATEF). To date, no manometric studies have been conducted on the intrathoracic stomach after GT in EATEF patients; hence, this study was designed. Babies ( n=18) of EATEF who underwent esophageal replacement by GT were studied and manometry was correlated with the clinical outcome, age at surgery, and route of GT. The mean age at evaluation was 30.5 months (range 4-84 months). These cases were sub-stratified into group I (GT during neonatal period) and group II (GT during post-neonatal period). Mean age at surgery was 6 days and 7.8 months in groups I and II, respectively. There was no propulsive antegrade propagated peristaltic waves in any of the patients. Mean resting pressure and mean peak pressures were 19.5 and 50.4 mm Hg in groups I and II, respectively. Mass contractions to liquid swallow was noted in 77 and 55% of patients in groups I and II, respectively. There was no significant difference in the pressure parameters or appearance of mass contractions between group-I and group-II patients. Similarly, there was no significant difference in pressure parameters or appearance of mass contractions between the children who had transhiatal vs retrosternal GT. It needs to be determined whether the mass contractions noted in GT ever progress to a coordinated propulsive rhythmic contractions and whether this has a final bearing on the long-term functional outcome of GT patients.

Whole stomach with antro-pyloric nerve preservation as an esophageal substitute: an original technique

The paper describes an original technique of gastric tailoring in which the two-thirds of the lesser curvature proximal to the crow's foot are denuded flush with the gastric wall, leaving both nerves of Latarjet and the hepatic branches of the left vagus nerve intact. Maintenance of the vagal supply to the antro-pyloric segment in two patients resulted in the presence of peristaltic contractions sweeping over the antrum on simple observation of the antral wall at the end of the procedure and on both upper G-I series and intragastric manometry tracings 6 weeks postoperatively. Gastric exposure to bile on 24-h gastric bile monitoring was normal 6 weeks after the operation. Neither patient had any gastrointestinal symptoms with the exception of early sensations of postprandial fullness when overeating.