A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy.
OBJECTIVE
Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage.


METHODS
Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study.


RESULTS
No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet.


CONCLUSIONS
Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.
Kent
M S
MS
University of Pittsburgh Medical Center, Suite C-800, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213, United States.
Pennathur
A
A
Fabian
T
T
McKelvey
A
A
Schuchert
M J
MJ
Luketich
J D
JD
Landreneau
R J
RJ
D001905:Botulinum Toxins / Q000008:administration & dosage* / Q000627:therapeutic use; D004334:Drug Administration Schedule; D004724:Endoscopy; D016629:Esophagectomy / Q000009:adverse effects*; D005746:Gastric Emptying / Q000187:drug effects*; D017219:Gastric Outlet Obstruction / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007267:Injections / Q000379:methods; D007430:Intraoperative Care; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects; D010865:Pilot Projects; D011182:Postoperative Care; D011708:Pylorus / Q000187:drug effects; D012189:Retrospective Studies; D013997:Time Factors
D001905:Botulinum Toxins