P-OGC73 Effect of pyloroplasty on the need for endoscopic intervention for delayed gastric emptying post oesophagectomy

Abstract Background Delayed gastric emptying (DGE) is a common complication following oesophagectomy, affecting 15-39% of patients. Controversy remains regarding the role of pyloric drainage procedures during oesophagectomy with gastric conduit reconstruction in reducing DGE. This study investigated the effect of pyloroplasty at the time of oesophagectomy on the need for endoscopic pyloric intervention post-operatively. Methods We performed a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 1 January 2010 and 31 December 2019. Electronic records were reviewed to analyse patient demographics, operative details and post-operative outcomes, as well as the need for endoscopic procedures after surgery. Patients were dichotomized into two groups, with those who had pyloroplasty performed at oesophagectomy compared to those who did not. Patients who died ≤30 days after oesophagectomy were excluded from analysis. Patients were followed up for a median of 32 months (IQR 19-60). Results 298 patients were eligible for the study, of whom 80/298 (26.8%) had a pyloroplasty performed. Demographics were evenly matched between the two groups. Patients undergoing Ivor-Lewis oesophagectomy were significantly more likely to have had pyloroplasty performed (90.0% vs. 24.3%; p < 0.001). Pyloroplasty had no significant effect on post-operative complication rates, ICU admission, need for re-operation or length of hospital stay. Patients without a pyloroplasty were significantly more likely to require endoscopic pyloric balloon dilatation (43.1% vs. 12.4%, p < 0.001) or pyloric botox injection (12.4% vs. 3.8%, p = 0.029) after oesophagectomy. Conclusions In this study, patients who had a pyloroplasty at the time of oesophagectomy were significantly less likely to require endoscopic pyloric balloon dilatation and/or pyloric botox injection post-operatively. This has significant long-term implications for both patients’ quality of life post-operatively and demands on over-stretched endoscopic services.

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Systematic review and meta-analysis of the influence of prophylactic pyloric balloon dilatation in the prevention of early delayed gastric emptying after oesophagectomy

Diseases of the Esophagus ◽

10.1093/dote/doab062 ◽

2021 ◽

Author(s):

Mohamed Abdelrahman ◽

Arun Ariyarathenam ◽

Richard Berrisford ◽

Lee Humphreys ◽

Grant Sanders ◽

...

Keyword(s):

Gastric Emptying ◽

Anastomotic Leak ◽

Balloon Dilatation ◽

Delayed Gastric Emptying ◽

Meta Analysis ◽

Length Of Hospital Stay ◽

Primary Outcome Measure ◽

Cochrane Library ◽

Secondary Outcome ◽

Optimal Approach

SUMMARY Background: Early delayed gastric emptying (DGE) occurs in up to 50% of patients following oesophagectomy, which can contribute to increased anastomotic leak and respiratory infection rates. Although the treatment of DGE in the form of pyloric balloon dilatation (PBD) post-operatively is well established, there is no consensus on the optimal approach in the prevention of DGE. The aim of this review was to determine the efficacy of prophylactic PBD in the prevention of DGE following oesophagectomy. Method: PubMed, MEDLINE and the Cochrane Library (January 1990 to April 2021) were searched for studies reporting the outcomes of prophylactic PBD in patients who underwent oesophagectomy. The primary outcome measure was the rate of DGE. Secondary outcome measures include anastomotic leak rate and length of hospital stay. Results: Three studies with a total of 203 patients [mean age 63 (26–82) years, 162 males (79.8%)] were analyzed. PBD with a 20-mm balloon was performed in 165 patients (46 patients had PBD and botox therapy) compared with 38 patients who had either no intervention or botox alone (14 patients). The pooled rates of early DGE [16.27%, 95% CI (12.29–20.24) vs. 39.02% (38.87–39.17) (P < 0.001)] and anastomotic leak [8.55%, 95% CI (8.51–8.59) vs. 12.23% (12.16–12.31), P < 0.001] were significantly lower in the PBD group. Conclusion: Prophylactic PBD with a 20-mm balloon significantly reduced the rates of early delayed gastric emptying and anastomotic leak following oesophagectomy.

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Routine Postoperative Upper Gastroesophageal Imaging is Unnecessary after Laparoscopic Roux-en-Y Gastric Bypass

The American Surgeon ◽

10.1177/000313480607201004 ◽

2006 ◽

Vol 72 (10) ◽

pp. 862-864

Author(s):

William Bertucci ◽

Stephen White ◽

John Yadegar ◽

Kaushal Patel ◽

Soo Hwa Han ◽

...

Keyword(s):

Gastric Bypass ◽

Gastric Emptying ◽

Patient Care ◽

Delayed Gastric Emptying ◽

Anastomotic Leaks ◽

Patient Demographics ◽

Prospective Database

Routine early postoperative upper gastroesophageal imaging (UGI) is often used in laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures to confirm anastomotic patency and to exclude leaks. The aim of our study was to assess the usefulness of this practice. From January 2003 to November 2004, 322 LRYGB cases were performed using linear staplers for the gastrojejunostomy and jejuno-jejunostomy anastomoses. As part of our protocol, all patients received a Gastrograffin® (Mallinkrodt, Inc., St Louis, Missouri) UGI on postoperative Day 1. The same radiological techniques were used and the same radiological team reviewed all films. Abnormal films were identified. In addition, patient demographics, time to discharge, and complications were collected and analyzed in a prospective database. There were no anastomotic leaks or obstructions. However, 42 of 322 (13%) studies demonstrated delayed gastric emptying. There were no statistically significant differences between patients with normal and delayed UGI studies. Routine UGI studies did not contribute significantly to patient care, and its routine use was subsequently abandoned.

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Balloon dilatation of the pylorus for delayed gastric emptying after esophagectomy☆

European Journal of Cardio-Thoracic Surgery ◽

10.1016/j.ejcts.2008.03.012 ◽

2008 ◽

Vol 33 (6) ◽

pp. 1105-1111 ◽

Cited By ~ 27

Author(s):

Jae-Hyun Kim ◽

Hyun-Sung Lee ◽

Moon Soo Kim ◽

Jong Mog Lee ◽

Seok Ki Kim ◽

...

Keyword(s):

Gastric Emptying ◽

Balloon Dilatation ◽

Delayed Gastric Emptying

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The role of choledochoscopy in transductal laparoscopic common bile duct exploration

General Surgery ◽

10.30978/gs-2021-1-10 ◽

2021 ◽

Author(s):

K. Atstupens ◽

H. Plaudis ◽

E. Saukane ◽

A. Rudzats

Keyword(s):

Bile Duct ◽

Common Bile Duct ◽

Common Bile Duct Exploration ◽

Complication Rates ◽

Time Saving ◽

Patient Demographics ◽

Operative Outcomes ◽

Additional Equipment ◽

Transcystic Approach ◽

A Prospective Study

Laparoscopic common bile duct exploration (LCBDE) performed by choledochoscope through the cystic duct or directly through the incision in the common bile duct (CBD) are well established methods for restoring biliary drainage function in patients with choledocholithiasis. Although it plays a crucial role in the transcystic approach, transductal approach can be achieved differently. However, it has restrictions in availability due to its expensiveness. Objective — to report efficacy of transductal LCBDE without laparoscopic choledochoscopy. Materials and methods. This is a prospective study of urgently admitted patients who underwent trans‑ductal LCBDE due to confirmed choledocholithiasis. During laparoscopy, clearance of the CBD was achieved in two ways: by choledochoscopy (group CS+, n = 43) and without it (group CS–, n = 34). The data of patient demographics, comorbidities, operative outcomes, morbidity, mortality and long‑term biliary complications were analysed and compared between the groups. Results. Out of a total of 154 patients with confirmed choledocholithiasis, the trans‑ductal approach of LCBDE was applied to 77 patients. In 43 patients, clearance was done with choledochoscope (group CS+) and in 34 patients without it (group CS–). Gallstone related complications and comorbidities did not differ between the groups. Surgery was done 4 days after admission in both groups. Median duration of the operation was significantly shorter in the group CS–, 93 vs 120 minutes (p = 0.036), without any difference in conversion and complication rates. Clearance rate was markedly high in both groups. Conclusions. Transductal laparoscopic common bile duct exploration without choledochoscopy is a time‑saving, safe and effective way for CBD clearance, without additional equipment.

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Outcomes of Minimally Invasive Esophagectomy without Pyloroplasty: Analysis of 109 Cases

The American Surgeon ◽

10.1177/000313481007601026 ◽

2010 ◽

Vol 76 (10) ◽

pp. 1135-1138 ◽

Cited By ~ 12

Author(s):

Ninh T. Nguyen ◽

Chirag Dholakia ◽

Xuan-Mai T. Nguyen ◽

Kevin Reavis

Keyword(s):

Gastric Emptying ◽

Minimally Invasive ◽

Delayed Gastric Emptying ◽

Operative Time ◽

Minimally Invasive Esophagectomy ◽

Gastric Function ◽

Invasive Esophagectomy ◽

Significant Difference ◽

Botox Injection

Pyloroplasty is performed during esophagectomy to avoid delayed gastric emptying. However, studies have shown that gastric function is minimally impaired even without a pyloroplasty when a gastric tube rather than the whole stomach is used for reconstruction. The aim of this study was to evaluate outcomes of minimally invasive esophagectomy without performance of a pyloroplasty. We performed a retrospective review of 145 patients who underwent a minimally invasive esophagectomy. The 30-day mortality was 2.1 per cent with an in-hospital mortality of 3.4 per cent. Of the 140 patients with more than 90 days follow-up, 31 patients had a pyloroplasty and 109 patients did not. One (3.2%) of 31 patients with pyloroplasty versus six (5.5%) of 109 patients without pyloroplasty developed delayed gastric emptying. There was no significant difference in the leak rate between the two groups (9.7% vs 9.6%, respectively). Total operative time was significantly shorter in the group without pyloroplasty (360 vs 222 minutes with a pyloroplasty, P < 0.01). Patients with delayed gastric emptying responded well to endoscopic pyloric dilation or Botox injection. The routine performance of a pyloroplasty during minimally invasive esophagectomy can be safely omitted with a reduction in operative time and minimal adverse effects on postoperative gastric function.

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Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2020.0136 ◽

2020 ◽

Vol 102 (9) ◽

pp. 693-696

Author(s):

EJ Nevins ◽

R Rao ◽

J Nicholson ◽

KD Murphy ◽

A Moore ◽

...

Keyword(s):

Botulinum Toxin ◽

Gastric Emptying ◽

Postoperative Period ◽

Delayed Gastric Emptying ◽

Gastric Conduit ◽

Significant Morbidity ◽

Biliary Reflux ◽

Pyloric Drainage ◽

Successful Resolution ◽

Procedural Complications

Introduction The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment. Methods All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP. Results Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7–16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications. Conclusions This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.

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P-P03 Impact of routine nasogastric decompression versus no nasogastric decompression after pancreatoduodenectomy on perioperative outcomes: A meta-analysis of available evidence

British Journal of Surgery ◽

10.1093/bjs/znab430.227 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Khaled Ammar ◽

Chris Varghese ◽

Thejasvin K ◽

Viswakumar Prabakaran ◽

Stuart Robinson ◽

...

Keyword(s):

Gastric Emptying ◽

Delayed Gastric Emptying ◽

Meta Analysis ◽

Length Of Hospital Stay ◽

Postoperative Pancreatic Fistula ◽

Current Evidence ◽

Perioperative Outcomes ◽

The Impact ◽

Nasogastric Decompression

Abstract Background This meta-analysis reviewed the current evidence on the impact of routine Nasogastric decompression (NGD) versus no NGD after pancreatoduodenectomy on perioperative outcomes. Methods PubMed, Medline, Scopus, Embase and Cochrane databases were searched for studies reporting the role of nasogastric tube decompression after pancreatoduodenectomy on perioperative outcomes were retrieved and analysed up to January 2021. Results Eight studies with total of 1301 patients were enrolled of which 668 patients had routine NGD. Routine NGD was associated with a higher incidence of overall delayed gastric emptying (DGE) and clinically relevant DGE (OR = 2.51, 95% CI; 1.12 - 5.63, I2= 83%, P = 0.03, and OR = 3.64, 95% CI: 1.83 – 7.25, I2 = 54%, P < 0.01, respectively). Routine NGD was also associated with a higher rate of Clavien-Dindo ≥ 2 complications (OR = 3.12, 95% CI: 1.05 – 9.28, I2 = 88%, P = 0.04), and increased length of hospital stay (MD = 2.67, 95% CI: 0.60 – 4.75, I2 = 97%, P = 0.02). There were no significant differences in overall complications (OR = 1.07, 95% CI: 0.79 – 1.46, I2 0%, P = 0.66), or postoperative pancreatic fistula (OR = 1.21, 95% CI: 0.86 – 1.72, I2 = 0%, P = 0.28) between the two groups. Conclusions Routine NGD may be associated with increased rates of DGE, major complications and longer length of stay after pancreatoduodenectomy.

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