title: Intrapyloric botulinum injection increases postoperative esophagectomy complications.
abstract: BACKGROUND
  Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy.
  
  
  METHODS
  We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both.
  
  
  RESULTS
  Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping.
  
  
  CONCLUSIONS
  Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Shady M
authors.initials: SM
authors.lastname: Eldaif
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Richard
authors.initials: R
authors.lastname: Lee
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Kumari N
authors.initials: KN
authors.lastname: Adams
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Patrick D
authors.initials: PD
authors.lastname: Kilgo
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Gruszynski
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Allan
authors.initials: A
authors.lastname: Pickens
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Fernandez
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Theresa D
authors.initials: TD
authors.lastname: Luu
authors.affiliation: Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address: daniel.miller@emoryhealthcare.org.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Miller
mesh_terms: D000368:Aged; D001905:Botulinum Toxins / Q000008:administration & dosage / Q000009:adverse effects*; D004322:Drainage; D016629:Esophagectomy / Q000009:adverse effects*; D005260:Female; D005746:Gastric Emptying; D006801:Humans; D007267:Injections; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*; D011708:Pylorus / Q000601:surgery; D012189:Retrospective Studies
chemical_list: D001905:Botulinum Toxins