Prevention of delayed gastric emptying after esophagectomy: a single center's experience with botulinum toxin.
BACKGROUND
Impaired gastric emptying after esophagectomy contributes to significant morbidity and delayed recovery. Traditional measures to prevent this include pyloromyotomy and pyloroplasty. These procedures are associated with known complications and do not always prevent delayed gastric emptying. Intrapyloric botulinum toxin injection may be an alternative approach to avoiding pyloric obstruction after esophagectomy.


METHODS
Patient data were collected in a prospective fashion at a single institution. Forty-eight patients underwent intrapyloric botulinum toxin injection during esophagectomy during a 26-month period (October 2005 to January 2008). Three patients were excluded from analysis because of complications, which interfered with postoperative evaluation of emptying. Forty-five patients were evaluated clinically for signs of delayed gastric emptying. Objective assessment included a dysphagia score in 15, barium swallow in 43, and nuclear gastric emptying scans in 15 patients. The data were also reviewed for evidence of aspiration events leading to pulmonary complications.


RESULTS
Forty-three of 45 patients (96%) had no clinical evidence of delayed gastric emptying in the immediate postoperative period. Four barium studies were interpreted as delayed gastric emptying; however, only 2 patients were symptomatic. These 2 patients underwent balloon pyloric dilation, which resulted in resolution of symptoms in 1. Three additional patients exhibited "late" delayed gastric emptying after initially doing well (mean of 3 months postoperatively) and required endoscopic intervention. No complications were identified in the study related to botulinum toxin injection.


CONCLUSIONS
Intrapyloric injection with botulinum toxin is a simple, safe, and effective means of avoiding delayed gastric emptying after esophagectomy. When necessary, reintervention may be performed endoscopically.
Martin
Jeremiah T
JT
Section of Thoracic Surgery, Department of Surgery, Hospital of St. Raphael, New Haven, Connecticut, USA.
Federico
John A
JA
McKelvey
Alicia A
AA
Kent
Michael S
MS
Fabian
Thomas
T
D018726:Anti-Dyskinesia Agents / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000627:therapeutic use*; D016629:Esophagectomy / Q000009:adverse effects*; D005746:Gastric Emptying / Q000187:drug effects*; D006801:Humans; D011446:Prospective Studies; D013272:Stomach Diseases / Q000209:etiology* / Q000517:prevention & control*; D013997:Time Factors
D018726:Anti-Dyskinesia Agents; D001905:Botulinum Toxins