Pyloric Drainage (Pyloroplasty) or No Drainage in Gastric Reconstruction after Esophagectomy: A Meta-Analysis of Randomized Controlled Trials

Abstract

Background/Aim: A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. The gastric emptying may be impaired after this operation, so some esophageal surgeons routinely add a pyloric drainage procedure (pyloroplasty or pyloromyotomy). We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of pyloric drainage on patient outcomes. Methods: Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of pyloric drainage procedures during gastric conduit reconstruction of the esophagus. The selection process was inclusive; no trials were excluded. Trial validity assessment was done, and a trial quality score was assigned. Early outcomes assessed by meta-analysis included operative mortality, esophagogastric anastomotic leaks, pulmonary morbidity, pyloric drainage complications, fatal pulmonary aspiration, and gastric outlet obstruction. A random-effects model was used, and the relative risk was the principal measure of effect. Systematic semiquantitative review was used for late outcomes such as gastric emptying, bile reflux, nutritional status, and obstructive foregut symptoms. Results: Nine RCTs, that included a total of 553 patients, were selected, with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. The relative risk (95% CI; p value), expressed as pyloric drainage versus no drainage (treatment vs. control), was 0.92 (0.34, 2.44; p = 0.86) for operative mortality, 0.90 (0.47, 1.76; p = 0.77) for esophagogastric anastomotic leaks, 0.69 (0.42, 1.14; p = 0.15) for pulmonary morbidity, 2.55 (0.34, 18.98; p = 0.36) for pyloric drainage complications, 0.25 (0.04, 1.60; p = 0.14) for fatal pulmonary aspiration, and 0.18 (0.03, 0.97; p = 0.046) for gastric outlet obstruction. Systematic semiquantitative review showed a nonsignificant trend favoring pyloric drainage for the late outcomes of gastric emptying, nutritional status, and obstructive foregut symptoms. For the late outcome of bile reflux, there was a nonsignificant trend favoring the no-drainage group. The scintographic gastric emptying time, expressed as a ratio (pyloric drainage/no drainage), was 0.53. Conclusions: Data synthesized from existing RCTs show 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.

Simplifying Minimally Invasive Transhiatal Esophagectomy With the Inversion Approach

“…No patient developed complications related to gastric outlet obstruction. While a drainage procedure has been reported to improve early motility, 14,15 it increases the complexity of the procedure, creates more bile reflux, and lengthens the operation.…”

Results after radical surgical treatment for advanced carcinoma of hypopharynx

“…On the contrary some authors do not share this idea and moreover they report that pyloromyotomy does not have an effect on pulmonary complications, hospital stay and mortality [36][37][38].…”

Duodenogastric Reflux after Esophagectomy and Gastric Interposition

“…The significance and value of adding a pyloroplasty or a pyloro myotomy at the end of the interposed stomach is still debated [24]. On one hand, it may facilitate gastric emptying, thus favoring a reduced exposure to reflu x.…”

“…Py loroplasty can lead to b ile reflu x to the cervical remnant through the gastric tube in the long term, and thereby lead to reflu x esophagitis in the cervical remnant. In fact, Urschel et al [24] reported that pyloroplasty reduces the occurrence of early postoperative gastric outlet obstruction, but it has little effect on the patient's late outcome. On the other hand, pyloroplasty may also pro mote duodenal reflu x and, in turn, facilitate the formation of the damaging reflu xate containg pancreato-biliary secretions mixed with gastric acid secretions.…”