title: Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation.
abstract: OBJECTIVE
  Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation.
  
  
  METHODS
  Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage.
  
  
  RESULTS
  The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96).
  
  
  CONCLUSIONS
  Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.
authors.affiliation: Massachusetts General Hospital, 55 Fruit Street, Blake 1570, Boston, MA 02114, United States. Mlanuti@partners.org
authors.forename: Michael
authors.initials: M
authors.lastname: Lanuti
authors.forename: Pierre E
authors.initials: PE
authors.lastname: de Delva
authors.forename: Cameron D
authors.initials: CD
authors.lastname: Wright
authors.forename: Henning A
authors.initials: HA
authors.lastname: Gaissert
authors.forename: John C
authors.initials: JC
authors.lastname: Wain
authors.forename: Dean M
authors.initials: DM
authors.lastname: Donahue
authors.forename: James S
authors.initials: JS
authors.lastname: Allan
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Mathisen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization / Q000379:methods*; D004322:Drainage / Q000379:methods; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D017219:Gastric Outlet Obstruction / Q000209:etiology / Q000517:prevention & control / Q000628:therapy*; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011708:Pylorus / Q000601:surgery*; D012189:Retrospective Studies