title: Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation.
abstract: BACKGROUND
  Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.
  
  
  METHODS
  We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.
  
  
  RESULTS
  From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05).
  
  
  CONCLUSIONS
  Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.|2 Department of Surgery, University of Cologne , Cologne, Germany .
authors.forename: Hans F
authors.initials: HF
authors.lastname: Fuchs
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Broderick
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Cristina R
authors.initials: CR
authors.lastname: Harnsberger
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Francisco Alvarez
authors.initials: FA
authors.lastname: Divo
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Alisa M
authors.initials: AM
authors.lastname: Coker
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Garth R
authors.initials: GR
authors.lastname: Jacobsen
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.|3 VA Healthcare , San Diego, California.
authors.forename: Bryan J
authors.initials: BJ
authors.lastname: Sandler
authors.affiliation: 4 Department of Surgery, University of California , San Diego, California.
authors.forename: Michael
authors.initials: M
authors.lastname: Bouvet
authors.affiliation: 1 Department of Surgery, Center for the Future of Surgery, University of California , San Diego, California.
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage* / Q000627:therapeutic use; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D004106:Dilatation; D004322:Drainage; D004724:Endoscopy; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007267:Injections; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D011707:Pyloric Stenosis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D011708:Pylorus / Q000601:surgery; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A