Comments on the publication “Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction by Palmes et al.”

Abstract

I read with interest the article by Palmes et al. [1] published in this journal. The issue of whether or not to perform a pyloric drainage after esophagectomy and gastric conduit reconstruction has previously been addressed by several investigators with contradictory results. More recently, the hypothesis that omitting pyloric drainage is safe after esophagectomy has been confirmed in a meta-analysis of nine randomised control trials which showed that a pyloroplasty reduced the occurrence of early gastric outlet obstruction but had little effect on mortality, morbidity and late foregut function [2]. The retrospective study by Palmes et al. nicely adds to this controversy by showing that pyloric drainage not only does not improve gastric emptying but it may also favour bile reflux and esophagitis. The multivariate analysis performed by the authors identified pyloric drainage and an anastomosis located below the level of the arch of the azygos vein as the independent risk factors associated with postoperative reflux esophagitis. However, the authors fail to mention that the size of the gastric conduit is another factor that may significantly affect the functional outcome of an esophagectomy. Using a tubularised stomach, as opposed to the whole stomach, may contribute to a faster emptying of the conduit due to reduced gastric wall distensibility and increased endoluminal pressurisation. After the laparoscopic gastric mobilisation has become the standard approach for esophagectomy in my department, I have gradually abandoned the practice of draining the pylorus. Between 2001 and 2007, 65 patients underwent an Ivor Lewis operation through laparoscopy and right thoracotomy for a type 1 or 2 adenocarcinoma of the distal esophagus/cardia according to Siewert classification. The lesser curve was routinely resected preserving the first three to four branches of the right gastric artery, and a 4-cm-wide gastric tube was constructed; in all patients, the esophago-gastric anastomosis was placed at the apex of the right chest. The incidence of clinically significant gastric outlet obstruction was 6.1% (4/65). All these individuals were relieved by a single or multiple sessions (median 2, range 1–3) of endoscopic pneumatic dilatation of the pylorus performed within the first year after the operation. It is noteworthy that Holscher et al. [3], in a recent series of 83 patients undergoing laparoscopic conditioning of the stomach for esophageal replacement, reported a 3.6% incidence of postoperative delayed gastric emptying; all individuals were relieved with endoscopic pneumatic dilation of the pylorus, and their further course was uneventful. In conclusion, I agree that pyloric drainage is not necessary after esophagectomy, provided that a narrow gastric conduit is used to replace the esophagus and the anastomosis is performed at the apex of the right chest. This may prevent duodenogastric reflux, as demonstrated by Palmes et al., and eliminates the potential risks associated to the laparoscopic pyloromyotomy or pyloroplasty. The occasional occurrence of postoperative gastric outlet obstruction can be safely treated by endoscopic pneumatic dilatation of the pylorus. Langenbecks Arch Surg (2008) 393:117–118 DOI 10.1007/s00423-007-0242-x