title: Comparison of pyloric intervention strategies at the time of esophagectomy: is more better?
abstract: 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.
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Mara B
authors.initials: MB
authors.lastname: Antonoff
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Bryan F
authors.initials: BF
authors.lastname: Meyers
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Kevin
authors.initials: K
authors.lastname: Baumgartner
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Bell
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Stephen
authors.initials: S
authors.lastname: Broderick
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: A Sasha
authors.initials: AS
authors.lastname: Krupnick
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri. Electronic address: crabtreet@wudosis.wustl.edu.
authors.forename: Traves D
authors.initials: TD
authors.lastname: Crabtree
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage; D004322:Drainage; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D017219:Gastric Outlet Obstruction / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011708:Pylorus / Q000601:surgery*; D012189:Retrospective Studies
chemical_list: D019274:Botulinum Toxins, Type A
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