Interact CardioVasc Thorac Surg 2007;6:247-250. doi:10.1510/icvts.2006.149500
© 2007 European Association of Cardio-Thoracic Surgery
Best evidence topic - Esophagus |
Does pyloroplasty following esophagectomy improve early clinical outcomes?
Omar A. Khana,
James Mannersa,
Arvind Rengarajanb and
Joel Dunningb,*
a Department of Cardiothoracic Surgery, Southampton General Hospital, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Received 28 November 2006;
accepted 5 December 2006
*Corresponding author. Tel./Fax: +44-780-1548122.
E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).
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Abstract
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A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether pyloroplasty following elective esophagectomy improves clinical outcomes. Altogether 170 relevant papers were identified using the below-mentioned search. One meta-analysis and six randomised controlled trials from the nine that were summarised in the meta-analysis represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that pyloroplasty seems to reduce the incidence of gastric outlet obstruction and speed up gastric emptying. In addition, the incidence of complications from this procedure seems low. However, other significant improvements to outcomes such as mortality, nutrition, anastomotic leakage, gastric symptoms and aspiration are yet to be established.
Key Words: Pyloroplasty; Esophagectomy; Evidence based medicine
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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You are performing an esophagectomy for a cT2N0M0 adenocarcinoma of the gastro esophageal junction. You have just mobilised the stomach and your surgical assistant asks whether you plan to perform a pyloroplasty as he has heard it is associated with improved early postoperative recovery. You do not routinely do this but decide to check the literature after the operation.
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3. Three-part question
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In [patients undergoing esophagectomy] does a [pyloric drainage procedure] improve [early or late clinical outcomes].
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4. Search strategy
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Medline 1966 to November 2006 using the OVID interface.
[exp esophagectomy/OR esophagectomy.mp or oesophagectomy.mp OR esophagus.mp OR oesophagus.mp OR retrosternal stomach.mp] AND [pyloroplasty.mp OR gastric drainage.mp OR pyloromyotomy.mp]
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5. Search outcome
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A total of 170 papers were identified. One meta-analysis was found that summarised nine randomised controlled trials. This study, together with the best six RCTs, were selected (Table 1).
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6. Discussion
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Although esophagectomy for cancer is a well-established operation, there exists much controversy as to the optimum surgical approach. With specific reference to routine pyloroplasty, advocates of this approach argue that this intervention prevents early gastric outlet obstruction associated with pyloric denervation, and hence, reduces the risk of pulmonary aspiration. By contrast, it has been argued that pyloroplasty is unnecessary as gastric outlet obstruction is a rare occurrence following esophagectomy and that the procedure itself is associated with a number of complications.
Urschel et al. [2] performed a meta-analysis in 2002, finding nine randomised controlled trials [3–11], that included 553 patients. They found non-significant trends towards a benefit of pyloroplasty for pulmonary morbidity (odds ratio 0.69 95% CI 0.42–1.14, P=0.15), pulmonary aspiration (odds ratio 0.25 95% CI 0.04–1.6, P=0.14), and a significant benefit for gastric outlet obstruction (odds ratio 0.18 95% CI 0.03–0.97, P=0.046). They also attempted to assess in a semi-quantitative fashion the results of later gastric symptoms reported by papers by assigning scores to outcomes described by the original papers. They found non-significant trends towards quicker gastric emptying, food intake, and foregut obstructive symptoms. They concluded that pyloric drainage procedures reduce the occurrence of early postoperative gastric outlet obstruction after esophagectomy with gastric reconstruction, but they have little effect on other early and late patient outcomes.
The largest RCT was by Fok et al. [3] in 1991, where 200 patients undergoing Lewis-Tanner esophagectomy were randomised to pyloroplasty or control. Thirteen patients without drainage developed obstructive symptoms compared to none in the drainage group. In addition, significant benefits were shown for early and late symptoms with meals, although all other outcome measures showed only non-significant trends towards benefit.
Zieren et al. [7] randomised 107 patients to pyloroplasty or control but found no significant differences between the two groups. However, the complication rates in this study were low in both groups.
Mannell et al. [5] performed a 40-patient RCT looking at gastric emptying, but again, due to the low incidence of symptoms, no significant differences were seen.
Chattopadhyay et al. [12] performed a small RCT to look at gastric emptying in 24 patients. Emptying was significantly delayed by more than 10 times in both groups post-operatively compared to preoperatively, but the difference was significantly better in the pyloroplasty group. There were no other differences in either group.
Kobayashi et al. [8] performed a 67-patient randomised trial looking at gastric function one and six months post esophagectomy. The food ejection time was reduced in the pyloroplasty group but most other markers including nutritional evaluation, lymphocyte count, rapid turnover protein and body weight fluctuation, were not significantly different.
Cheung et al. [13] performed a 72 patient randomised study looking at gastric emptying and late symptoms. They showed significantly quicker gastric emptying at six months, although symptoms did not correlate well with this improvement in transit time. They deemed that two patients in the control group could have benefited from pyloroplasty as the remainder were completely symptom free on follow up.
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7. Clinical bottom line
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Pyloroplasty seems to reduce the incidence of gastric outlet obstruction and speed up gastric emptying. In addition, the incidence of complications from this procedure seems low. However, other significant improvements to outcomes such as mortality, nutrition, anastomotic leakage, gastric symptoms and aspiration, are yet to be established.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
- Urschel JD, Blewett CJ, Young JE, Miller JD, Bennett WF. Pyloric drainage (pyloroplasty) or no drainage in gastric reconstruction after esophagectomy: a meta-analysis of randomized controlled trials. Digest Surg 2002; 19:160–164.
- Fok M, Cheng SW, Wong J. Pyloroplasty versus no drainage in gastric replacement of the esophagus. Am J Surg 1991; 162:447–452.[CrossRef][Medline]
- Gupta S, Chattopadhyay TK, Gopinath PG, Kapoor VK, Sharma LK. Emptying of the intrathoracic stomach with and without pyloroplasty. Am J Gastroenterol 1989; 84:921–923.[Medline]
- Mannell A, McKnight A, Esser JD. Role of pyloroplasty in the retrosternal stomach: results of a prospective, randomized, controlled trial. Br J Surg 1990; 77:57–59.[Medline]
- Chattopadhyay TK, Shad SK, Kumar A. Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy. Br J Surg 1993; 80:371–373.[CrossRef][Medline]
- Zieren HU, Muller JM, Jacobi CA, Pichlmaier H. Should a pyloroplasty be carried out in stomach transposition after subtotal esophagectomy with esophago-gastric anastomosis at the neck? A prospective randomized study. [German]. Chirurg 1995; 66:319–325.[Medline]
- Kobayashi A, Ide H, Eguchi R, Nakamura T, Hayashi K, Hanyu F. The efficacy of pyloroplasty affecting to oral-intake quality of life using reconstruction with gastric tube post esophagectomy [Japanese]. Nippon Kyobu Geka Gakkai Zasshi – J Jpn Ass Thor Surg 1996; 44:770–778.
- Huang GJ, Zhang DC, Zhang DW. A comparative study of resection of carcinoma of the esophagus with and without pyloroplasty. In: DeMeester TR, Skinner DB. Esophageal Disorders1985;New York: Raven Press 383–387. In.
- Kao CH, Chen CY, Chen CL, Wang SJ, Yeh SH. Gastric emptying of the intrathoracic stomach as oesophageal replacement for oesophageal carcinomas. Nucl Med Commun 1994; 15:152–155.[Medline]
- Hsu HK, Huang MH, Chien KY, Liu RS, Yeh SH. Functional evaluation of using the stomach as an esophageal substitute. J Surg Assoc ROC 1984; 17:186–188.
- Chattopadhyay TK, Gupta S, Padhy AK, Kapoor VK. Is pyloroplasty necessary following intrathoracic transposition of stomach? Results of a prospective clinical study. Aust NZ J Surg 1991; 61:366–369.[Medline]
- Cheung HC, Siu KF, Wong J. Is pyloroplasty necessary in esophageal replacement by stomach? A prospective, randomized controlled trial. Surgery 1987; 102:19–24.[Medline]
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Abstract
1. Introduction