Pylorus drainage procedures in thoracoabdominal esophagectomy - a single-center experience and review of the literature

Comprehensive review of therapeutic procedures for delayed gastric conduit emptying after esophagectomy

BACKGROUND

Delayed gastric conduit emptying (DGCE) is a common functional complication after esophagectomy that significantly impairs the quality of life. Despite its clinical burden, standardized management protocols are lacking, and treatment approaches often rely on individual surgeon preference. This review aimed to evaluate the evidence on procedural interventions for established late DGCE to inform clinical decision-making.

METHODS

A systematic review was conducted across 5 databases, identifying 26 studies on DGCE interventions. Studies were assessed for quality using the Newcastle-Ottawa Scale, emphasizing the inclusion criteria that focused on procedural efficacy and outcome reporting.

RESULTS

A total of 26 studies encompassing diverse treatment modalities were included. Endoscopic approaches, such as botulinum toxin injection and balloon dilatation, have emerged as preferred first-line interventions, with success rates ranging from 50.0% to 100.0%. A hybrid approach combining both modalities demonstrated enhanced efficacy and lower recurrence, with success rates reaching 100.0%. Gastric peroral endoscopic myotomy showed promise for treatment-resistant DGCE, with experienced centers reporting success in 77.2% of refractory cases. Surgical options for gastric conduit revision were reserved for cases of DGCE with structural abnormalities, although the surgical options were associated with higher risks and complications. Significant heterogeneity in outcome definitions and reporting limited the comparability between studies.

CONCLUSION

This comprehensive evaluation provides valuable insights to assist clinicians in navigating current management strategies for DGCE. High-quality comparative studies are essential to refine treatment protocols and improve long-term patient outcomes.

Effect of pyloroplasty on clinical outcomes following esophagectomy

INTRODUCTION

The role of concurrent pyloroplasty with esophagectomy is unclear. Available literature on the impact of pyloroplasty during esophagectomy on complications and weight loss is varied. Data on the need for further pyloric intervention are scarce. Our study compares the clinical outcomes after esophagectomy with or without pyloroplasty and investigates the role of post-operative pyloric dilatation.

METHODS

Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, mortality rate, anastomotic leak, respiratory complications (Clavien-Dindo grade ≥ 3), anastomotic stricture rate, and percentage weight loss at 1 and 2 year post-operatively were evaluated. For weight analysis at 1 and 2 year post-operatively, patients were excluded if they had been diagnosed with recurrence or died prior to the 1 or 2 year timepoints.

RESULTS

Ninety-two patients did not have a pyloroplasty, and 115 patients had a pyloroplasty. There were no complications resulting from pyloroplasty. There was no significant demographic difference between the groups except for age. Mortality rate, anastomotic leak, respiratory complications, anastomotic stricture rate, and percentage weight loss at 1 and 2 years were statistically similar between the two groups. However, 14.1% of patients without pyloroplasty required post-operative endoscopic pyloric balloon dilatation to treat respiratory complications or gastroparesis. Subgroup analysis of patients without pyloroplasty indicated that patients requiring dilatation had greater weight loss at 1 year (15.8% vs 9.4%, p = 0.02) and higher respiratory complications rate (27.3% vs 4.7%, p = 0.038).

CONCLUSIONS

Overall results from our study that pyloroplasty during Ivor Lewis esophagectomy is safe and useful to prevent the need for post-operative pyloric dilatation.

Gastric Tube Volvulus Occurring Years After Esophagectomy and Its Successful Treatment Via Endoscopic Stenting

Esophageal cancer is frequently treated with esophagectomy, which is associated with distinct complications. Delayed gastric conduit emptying is a well-recognized complication that usually occurs within the postoperative period. By contrast, gastric tube volvulus is a rarer complication with a more variable time course of onset after esophagectomy and can be mistaken for delayed gastric conduit emptying. We describe the fifth reported case of gastric tube volvulus occurring years after esophagectomy and its successful treatment via endoscopic stenting.

Anterior gastric wall anastomosis may lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study

INTRODUCTION

In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes.

MATERIAL AND METHODS

All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database.

RESULTS

Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien-Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST.

CONCLUSION

Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying.

Effect of intraoperative botulinum toxin injection on delayed gastric emptying and need for endoscopic pyloric intervention following esophagectomy: a systematic review, meta-analysis, and meta-regression analysis

The aim of this study was to evaluate the effect of intraoperative botulinum toxin (BT) injection on delayed gastric emptying (DGE) and need for endoscopic pyloric intervention (NEPI) following esophagectomy. In compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a systematic review of studies reporting the outcomes of intraoperative BT injection in patients undergoing esophagectomy for esophageal cancer was conducted. Proportion meta-analysis model was constructed to quantify the risk of the outcomes and direct comparison meta-analysis model was constructed to compare the outcomes between BT injection and no BT injection or surgical pyloroplasty. Meta-regression was modeled to evaluate the effect of variations in different covariates among the individual studies on overall summary proportions. Nine studies enrolling 1070 patients were included. Pooled analyses showed that the risks of DGE and NEPI following intraoperative BT injection were 13.3% (95% confidence interval [CI]: 7.9-18.6%) and 15.2% (95% CI: 7.9-22.5%), respectively. There was no difference between BT injection and no BT injection in terms of DGE (odds ratio [OR]: 0.57, 95% CI: 0.20-1.61, P = 0.29) and NEPI (OR: 1.73, 95% CI: 0.42-7.12, P = 0.45). Moreover, BT injection was comparable to pyloroplasty in terms of DGE (OR: 0.85, 95% CI: 0.35-2.08, P = 0.73) and NEPI (OR: 8.20, 95% CI: 0.63-105.90, P = 0.11). Meta-regression suggested that male gender was negatively associated with the risk of DGE (coefficient: -0.007, P = 0.003). In conclusion, level 2 evidence suggests that intraoperative BT injection may not improve the risk of DGE and NEPI in patients undergoing esophagectomy. The risk of DGE seems to be higher in females and in early postoperative period. High quality randomized controlled trials with robust statistical power are required for definite conclusions. The results of the current study can be used for hypothesis synthesis and power analysis in future prospective trials.

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 .

Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis

PURPOSE

Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure.

METHODS

A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention.

RESULTS

Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29).

CONCLUSION

Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.

Effect of modified esophagectomy perioperative technique resection for patients with locally advanced esophageal cancer (tumor length > 8 cm): initial experience in 45 cases

Background

Patients with locally advanced esophageal cancer with a lesion length greater than 8 cm (LCWEC) are prone to high mortality in a short time due to esophagotracheal fistula (ETF) and esophagoaortic fistula (EAF). We tried to explore a safe salvage surgical method during the perioperative period to maximize the resection of the tumor on the premise of safety and reconstruction of the alimentary tract to avoid early death due to ETF and EAF.

Methods

From December 2007 to November 2018, forty-five LCWEC patients were treated using the modified Wu’s esophagectomy. Patient features, surgical techniques, postoperative complications, and pathology outcomes were analyzed.

Results

The average length of the tumors was 12.5 cm (range 8.1–22.5 cm), and the average transverse tumor diameter was 5.8 cm (range 4.5–7.8 cm). No complications like anastomotic leakage, anastomotic stenosis, chylothorax, delayed gastric emptying, vocal cord paralysis, dumping syndrome, and reflux were detected. The 30-day and in-hospital mortality rates were 0%. Complete (R0) resection was achieved in 38 (84.4%) cases. The resection margin rate of positive anastomosis was 0%. Until the death of the patients, no feeding failure due to gastrointestinal obstruction and early death due to ETF or EAF occurrence. During follow-up, the median time to death was 17.2 months for patients treated with surgery alone and 32 months for patients treated with postoperative multimodal treatment.

Conclusion

The modified Wu’s esophagectomy is a safe and feasible salvage surgical method for LCWEC resection.

Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation

INTRODUCTION

Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation.

METHODS

Between 2015 and 2018, patients with delayed gastric emptying 8-10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon.

RESULTS

Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9-15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events.

CONCLUSION

Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.

Exaggerated postprandial GLP-1 secretion following esophagectomy is not associated with gastric emptying and intestinal transit

Esophagectomy causes postprandial symptoms associated with an exaggerated postprandial gut hormone response. This study aimed to compare the gastrointestinal transit time of patients 1 year after esophagectomy with unoperated controls, including its relation to satiety gut hormone release. In this cross-sectional study, consecutive, disease-free patients after esophagectomy with pyloroplasty were compared with unoperated control subjects to assess gastric emptying (GE) and cecal arrival time (CAT). Serial plasma samples were collected before, and for 300 minutes after, a mixed-meal challenge. Body composition was assessed, and symptom scores were calculated. Eleven patients 1 year post-esophagectomy (age: 62.6 ± 9.8, male: 82%) did not show a significantly different GE pattern compared with 10 control subjects (P = 0.245). Rather, patients could be categorized bimodally as exhibiting either rapid or slow GE relative to controls. Those with rapid GE trended toward a higher postprandial symptom burden (P = 0.084) without higher postprandial glucagon-like peptide-1 (GLP-1) secretion (P = 0.931). CAT was significantly shorter after esophagectomy (P = 0.043) but was not significantly associated with GE, GLP-1 secretion, or symptom burden. Neither early nutrient delivery to the proximal small intestine nor to the colon explains the exaggerated postprandial GLP-1 response after esophagectomy. GE varies significantly in these patients despite consistent pyloric management.

Delayed Gastric Emptying Post-Esophagectomy: A Single-Institution Experience

OBJECTIVE

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy in patients with esophageal carcinoma. Management of DGE varies widely and it is unclear how comorbidities influence the postoperative course. This study sought to determine factors that influence postoperative DGE.

METHODS

This retrospective study evaluates patients who underwent esophagectomy with gastric pull-up between 2007 and 2019. The cohort was stratified in various ways to determine if postoperative care and outcomes differed, including patient demographics, comorbidities, intraoperative and postoperative procedures.

RESULTS

During the study period, 149 patients underwent esophagectomy and 37 had diabetes. Overall incidence of DGE, as defined in this study, was 76.5%. Surgery type was significantly different between DGE and normal emptying cohorts (P = 0.005). Comparing diabetic and nondiabetic patients, there was no significant difference noted in DGE (P = 0.25). Additionally, there was no difference in presence of DGE for patients who underwent any intraoperative pyloric procedure compared to those who did not (P = 0.36). Of significance, all 16 patients with chronic obstructive pulmonary disease had a delay in gastric emptying (P = 0.01).

CONCLUSIONS

A higher proportion of patients with DGE post-esophagectomy were identified compared to the literature. There is little consensus on a true definition of DGE, but we believe this definition identifies patients suffering in the immediate postoperative period and in follow-up. There is no evidence to support a different postoperative course for patients with diabetes, but the link between chronic obstructive pulmonary disease and DGE warrants further investigation.

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.

Surgical Adjuncts During Esophagectomy

Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.

Reinforcement of intrathoracic oesophago-gastric anastomosis with fibrin sealant (Tisseel®) in oesophagectomy for cancer: A prospective comparative study

PURPOSE

Fibrin sealant (Tisseel) is a human protein and thrombin soluble fibrinogen that has been indicated for reinforcement of gastro-intestinal anastomoses to prevent leakage. The objective of this study is to examine the impact of fibrin sealant regarding anastomotic leak, following Ivor-Lewis procedure.

METHODS

This is a prospective comparative study on 2-stage oesophagectomy for cancer of the distal oesophagus or oesophagogastric junction. N = 57 individuals were randomly subjected; n = 22 patients to Tisseel in combination to surgical anastomosis versus n = 35 patients to surgical anastomosis alone. The test of probability was assessed through Chi-Square, independent samples paired T-Test and Log-Rank analysis.

RESULTS

Of the 57 cases included, 56 underwent hybrid and 1 open oesophagectomy. In the Tisseel group, n = 5(22.7%) developed anastomotic leak comparing to n = 3(8.6%) of the control group. No statistically significant difference in leak rate was shown between the two groups; the test of probability was rejected.

CONCLUSIONS

Our results are not supportive of Tisseel tissue sealing property on the intrathoracic oesophago-gastric anastomosis and fibrin sealant's use cannot be justified.

Reconstructed gastric conduit obstruction caused by a bezoar after esophagectomy: a case report

BACKGROUND

Bezoars are rare but may cause gastrointestinal obstruction and ulcers. To the best of our knowledge, only two cases of bezoars in the reconstructed gastric conduit have been reported, but there has been no report on reconstructed gastric conduit obstruction due to bezoars.

CASE PRESENTATION

A 60-year-old man presented to our clinic with abdominal pain and vomiting that occurred suddenly after dinner. Three years before presentation, he had undergone radical thoracoscopic esophagectomy followed by reconstruction of the gastric conduit through the posterior sternum, for esophageal cancer. Enhanced computed tomography scans showed distension of only the gastric conduit without ischemia and distension of the small intestine. According to our findings, we initially diagnosed the patient with postoperative intestinal obstruction caused by adhesions. After conservative treatment failed, the patient underwent an endoscopic study that showed a bezoar at the pylorus ring. We initially failed to remove the bezoar endoscopically because of its large size; hence, we attempted enzymatic dissolution. Three days after the first endoscopic study, the bezoar was disintegrated using a snare and extracted during a second endoscopy. The patient recovered uneventfully and presented with no complications during the 1-year follow-up interval.

CONCLUSION

In cases wherein the discharge of materials in the reconstructed gastric conduit is delayed, bezoars should be considered in the differential diagnosis, and an endoscopic study should be performed to verify the cause of obstruction.

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.

Influencing factors of postoperative early delayed gastric emptying after minimally invasive Ivor-Lewis esophagectomy

BACKGROUND

The main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy (MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying (DGE).

AIM

To investigate the influencing factors of postoperative early DGE after MIILE.

METHODS

A total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group (n = 49) and a control group (n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic (ROC) curve was used to assess potential factors in predicting postoperative early DGE.

RESULTS

Age, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group (P < 0.05). Age, anxiety score, perioperative albumin level, and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant (P < 0.05). The ROC curve analysis revealed that the area under the curve (AUC) for anxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L, and the sensitivity and specificity were 97.2% and 46.9%, respectively.

CONCLUSION

Advanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.

Management of delayed gastric conduit emptying after esophagectomy

Delayed gastric conduit emptying (DGE) is a common complication after esophagectomy. Currently, pyloric interventions are the major prevention and treatment for DGE. In this review, we attempt to evaluate the clinical effect and safety of different pyloric interventions in esophagectomy patients. Moreover, other important management of DGE, including size of esophageal substitute, erythromycin and nasogastric tube (NGT) will also be discussed.