title: Is Chemical Pyloroplasty Necessary for Minimally Invasive Esophagectomy?
abstract: BACKGROUND
  Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients.
  
  
  METHODS
  The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student's t test, χ2analysis, and Mann-Whitney U test where appropriate.
  
  
  RESULTS
  The study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p > 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention.
  
  
  CONCLUSIONS
  In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. Camille.Stewart@ucdenver.edu.
authors.forename: Camille L
authors.initials: CL
authors.lastname: Stewart
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Lauren
authors.initials: L
authors.lastname: Wilson
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Aidan
authors.initials: A
authors.lastname: Hamm
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Christan
authors.initials: C
authors.lastname: Bartsch
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Megan
authors.initials: M
authors.lastname: Boniface
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Gleisner
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Mitchell
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Weyant
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Meguid
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Csaba
authors.initials: C
authors.lastname: Gajdos
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Barish H
authors.initials: BH
authors.lastname: Edil
authors.affiliation: Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Martin
authors.initials: M
authors.lastname: McCarter
mesh_terms: D000368:Aged; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005746:Gastric Emptying; D017219:Gastric Outlet Obstruction / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D011708:Pylorus / Q000187:drug effects*; D012189:Retrospective Studies
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A