Endoscopic Pyloric Dilation Research Articles

OGC P56 Preliminary results from the use of a symptom response questionnaire following pyloric dilatation for delayed gastric emptying post-oesophagectomy

Abstract Background Patient symptom burden following oesophago-gastrectomy is high with numerous potential underlying causes which can often overlap. Diagnostic test results and the symptom response to a given intervention may provide important insights, yet there are no validated questionnaires to support the latter. Delayed gastric emptying is a common problem after oesophagectomy, significantly affecting patients' quality of life. The most common treatment option is to perform an endoscopic pyloric dilatation. However, there is no tool available to measure its effect on patient's quality of life. We have developed a symptom response questionnaire to evaluate the impact of the pyloric dilatation procedure. Methods With patient involvement, a symptom response to treatment questionnaire was developed based on validated EORTC symptom questions. Although designed to assess symptom response to any intervention, consecutive patients referred for suspected delayed gastric emptying who received an endoscopic pyloric dilatation from a single center were included in this study. Patients were contacted by telephone at two and four weeks after the procedure to complete the symptom response questionnaire. The investigators contacting the patients were neither their surgeon nor the one who performed the endoscopic procedure. We excluded all patients receiving other endoscopic treatment than a pyloric dilatation. Results 27 patients responded to the questionnaire at 2 and 4 weeks. The main reported symptoms were dysphagia in 15 patients (58%) and reflux in 6 patients (21%). An improvement in symptom frequency was noted in 23 patients (85%) at two weeks. A subsequent worsening in the patient symptom frequency was noted in 3 patients (8.8%) between two and four weeks. Regarding the severity of the symptom, an improvement was observed in 24 out of 27 patients (88%) after two weeks, and no patients reported a worsening of symptom severity at the four-weeks call. Conclusions The symptom response questionnaire aimed at evaluating the impact of pyloric dilatation was easily implemented and well-received by the patients for completion. By providing a structured and patient-centred approach, this questionnaire can serve as a basis for monitoring and understanding the effectiveness of endoscopic interventions in improving the quality of life for patients with delayed gastric emptying. An electronic version of the questionnaire has been developed and will be tested in the near future.

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients.

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65years, P= 0.6), pathological stage (P= 0.10) or ASA status (P= 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P= 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P= 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P= 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.

Efficacy and safety of endoscopic pyloric balloon dilation in patients with refractory gastroparesis.

There has been interest in the use of pyloric therapies for the treatment of refractory gastroparesis. However, data on endoscopic pyloric dilation are scarce. We aimed to assess the efficacy and safety of this procedure in refractory gastroparesis. We performed a retrospective analysis of 47 patients referred for refractory gastroparesis, confirmed by gastric emptying scintigraphy, and treated with endoscopic pyloric through-the-scope balloon dilation. The primary endpoint was the effectiveness of the procedure, evaluated with the Gastric Cardinal Symptom Index (GCSI) at 2 and 6months. A clinical response, defined by a 1.0 point decrease in the GCSI score, was observed in 25 patients at 2months (53%) and in 19 patients at 6months (40%). The mean GCSI score decreased significantly at 2 and 6months compared to the preoperative score (3.9 ± 0.87 vs 2.3 ± 1.37 and 3.9 ± 0.87 vs 2.9 ± 1.27, respectively; p < 0.0001). No complication was observed. Nine patients had a delayed relapse at 1year. A second dilation was performed for eight patients and it was effective in five of them (63%). The mean follow-up time of the patients was 27.0 ± 10.4months. At 2years, 15 patients still experienced improvement following this treatment (32%). No predictive factor of clinical response was identified. The efficacy of pyloric dilation is 53% at 2months, with sustained improvement in one third of patients at 2years. This treatment should be considered as an alternative option to pyloromyotomy.

Characteristics of patients who underwent gastric electrical stimulation vs. surgical pyloric interventions for refractory gastroparesis.

Background:There has been recent debate comparing the efficacy of gastric electrical stimulation (GES) with pyloric intervention, but medical literature lacks clear indications for when to perform GES or pyloric intervention. This study aims to assess the effect of sociodemographic factors and hospital characteristics on the surgical technique chosen for the treatment of gastroparesis.Methods:Data was extracted from the National Inpatient Sample between the years 2012 and 2014, using any discharge diagnosis of gastroparesis. For comparison of analysis between GES and pyloric surgical intervention, pyloroplasty, endoscopic pyloric dilation, and pyloromyotomy were considered to be pyloric interventions. The study population was divided into two groups, one which received GES and the other receiving pyloric intervention, to compare socioeconomic factors and hospital characteristics.Results:In total, 737,930 hospitalizations had a discharge diagnosis of gastroparesis between 2012 and 2014. On weighted multivariant analysis of patients undergoing GES or pyloric intervention for gastroparesis, being female (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.25–1.78; P < 0.001), being Hispanic (OR 1.75, 95%CI; P < 0.001), being in urban teaching (OR 1.41, 95%CI 1.15–1.72; P < 0.001), and nonteaching hospitals (OR 2.93, 95%CI 2.4–3.58; P < 0.001), early satiety (OR 6.70, 95%CI 1.54–31.25; P = 0.01), and diabetes mellitus (OR 2.14, 95%CI 1.78–2.56; P < 0.001) were each statistically significantly correlated with receiving GES intervention compared to pyloric intervention.Conclusion:The racial difference, payer source, and hospital location affected the surgical intervention (GES or pyloric intervention) that patients with gastroparesis would receive.

Treatment Utilization and Socioeconomic Disparities in the Surgical Management of Gastroparesis

BackgroundGastroparesis is an end-organ sequela of diabetes. We evaluated the roles of race and socioeconomic status in hospitalization rates and utilization of surgical treatments in these patients. MethodsData was extracted from the National Inpatient Sample (NIS) between the years 2012 and 2014, and any discharge diagnosis of gastroparesis (536.3) was included. Gastrostomy, jejunostomy, and total parenteral nutrition were considered nutritional support procedures, and procedures aimed at improving motility were considered definitive disease-specific procedures: pyloroplasty, endoscopic pyloric dilation, gastric pacemaker placement, and gastrectomy. ResultsThere were 747,500 hospitalizations reporting a discharge diagnosis of gastroparesis. On multivariable analysis, black race (OR 1.93, 95% CI 1.89–1.98; p < 0.001) and Medicaid insurance (OR 1.46, 95% CI 1.42–1.50; p < 0.001) were the strongest socioeconomic risk factors for hospitalization due to gastroparesis. Patients in urban teaching institutions were most likely to undergo a surgical intervention for gastroparesis (5.53% of patients versus 3.94% of patients treated in urban non-teaching hospitals and 2.38% of patients in rural hospitals; p < 0.001). Uninsured patients were less than half as likely to receive treatment compared to those with private insurance (OR 0.41, 95% CI 0.34–0.48; p < 0.001), and black patients had an OR 0.75 (95% CI 0.69–0.81; p < 0.001) for receiving treatment. Urban teaching hospitals had a twofold higher likelihood of intervention (OR 2.12, 95% CI 1.84–2.44; p < 0.001). ConclusionsMarked racial and economic disparities exist in surgical distribution of care for gastroparesis, potentially driven by differences in utilization of care.

RA01.08: LAPAROSCOPIC ROUX-EN-Y GASTROJEJUNOSTOMY FOR GASTRIC CONDUIT OUTLET OBSTRUCTION FOLLOWING ESOPHAGECTOMY FOR CANCER

Abstract Description After Ivor Lewis esophagectomy, gastric outlet obstruction refractory to prokinetic therapy and/or endoscopic pyloric dilatation is a challenging clinical problem. Thoracoscopic implant of a gastric neurostimulator has been reported to be effective, but long-term results are lacking. The patient, a 57-year-old woman, underwent a Ivor Lewis esophagectomy for T1N0 adenocarcinoma in 2007. Postoperatively, the patient complained of persistent dysphagia, regurgitation, and 29-kg weight loss. A mechanical obstruction was ruled out by barium swallow study and upper gastrointestinal endoscopy. Several conservative attempts with prokinetic agents and endoscopic dilatations failed, and the patient was exclusively fed through jejunostomy until the thoracoscopic implant of a gastric neurostimulator in October 2015. The postoperative course was uneventful. At six-months follow-up, the patient was able to assume a soft diet and reported a weight gain of 3 kg, with a significant improvement of the total symptom score and gastric emptying scintigraphy. Nevertheless, this encouraging clinical benefit gradually disappeared after the first year of follow-up. At the beginning of 2017, the patient experienced persistent episodes of vomiting and returned to jejunostomy feeding. The video shows the technique of laparoscopic Roux-en-Y gastrojejunostomy. After adhesiolysis and transhiatal mobilization of the distal gastric conduit, a 50 cm long Roux-en-Y alimentary limb was fashioned and anastomosed to the antrum. Post-operative course was uneventful and a gastrographin swallow study showed a satisfactory emptying of the conduit. At the 3-month follow-up the patient was able to resume a soft oral diet. Laparoscopic Roux-en-Y gastrojejunostomy appears to be safe and effective in treating refractory gastric outlet obstruction following Ivor-Lewis esophagectomy. Disclosure All authors have declared no conflicts of interest.

Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage

BackgroundThe incidence of delayed gastric emptying (DGE) after esophagectomy is 10%-50%, which can interfere with postoperative recovery in the short-term and result in poor quality of life in the long term. Pyloric drainage is routinely performed to prevent DGE, but its role is highly controversial. The aim of this study was to report the rate of DGE after esophagectomy without pyloric drainage and to investigate its risk factors and the potential effect on recovery. Materials and methodsBetween January 2010 and January 2015, we analyzed 285 consecutive patients who received an esophagectomy without pyloric drainage. Possible correlations between the incidence of DGE and its potential risk factors were examined in univariate and multivariate analyses, respectively. The outcomes of DGE were reviewed with a follow-up of 3 mo. ResultsThe overall rate of DGE after esophagectomy was 18.2% (52/285). Among perioperative factors, gastric size (gastric tube versus the whole stomach) was the only significant factor affecting the incidence of DGE in the univariate analysis. The patients who received a whole stomach as an esophageal substitute were more likely to develop DGE than were patients with a gastric tube (13.2% versus 22.4%; P = 0.05). No independent risk factor for DGE was found in the multivariate analysis. The incidence of major postoperative complications, including anastomotic leak, respiratory complications, and cardiac complications, was also not significantly different between both groups, with or without DGE. Within 3 mo of follow-up, most patients could effectively manage their DGE through medication (39/52) or endoscopic pyloric dilation (12/52), with only one patient requiring surgical intervention. ConclusionsIn our study, the overall incidence of DGE is about 20% for patients undergoing esophagectomy without pyloric drainage. Compared with prior findings, this does not result in a significantly increased incidence of DGE. In patients with symptoms of DGE after esophagectomy, prokinetic agents and endoscopic balloon dilation of the pylorus can be effective, as indicated by the high success rate and lack of significant complications.

Gastric Outlet Obstruction After Esophagectomy: Retrospective Analysis of the Effectiveness and Safety of Postoperative Endoscopic Pyloric Dilatation.

Delayed gastric emptying after esophagectomy with gastric replacement can pose a significant postoperative problem, often leading to aspiration and pneumonia. The present study analyzes retrospectively the effectiveness of endoscopic pyloric dilatation for post-surgical gastric outlet obstruction. Between March 2006 and March 2010, 403 patients underwent a transthoracic en-bloc esophagectomy and reconstruction with a gastric tube and intrathoracic esophagogastrostomy. In patients with postoperative symptoms of an outlet dysfunction and the confirmation by endoscopy, pyloric dilatations were performed without preference with either 20- or 30-mm balloons. A total of 89 balloon dilatations of the pylorus after esophagectomy were performed in 60 (15.6%) patients. In 21 (35%) patients, a second dilatation of the pylorus was performed. 55 (61.8%) dilatations were performed with a 30-mm balloon and 34 (38.2%) with a 20-mm balloon. The total redilatation rate for the 30-mm balloon was 20% (n=11) and 52.9% (n=18) for the 20-mm balloon (p<0.001). All dilatations were performed without any complications. Pylorus spasm contributes to delayed gastric emptying leading to postoperative complications after esophagectomy. Endoscopic pyloric dilatation after esophagectomy is a safe procedure for treatment of gastric outlet obstruction. The use of a 30-mm balloon has the same safety profile but a 2.5 lower redilatation rate compared to the 20-mm balloon. Thus, the use of 20-mm balloons has been abandoned in our clinic.

Vascular Injury Following Pyloric Dilation: Unusual Cause of Ischemic Colitis

A 57-year-old female with intrahepatic cholangiocarcinoma underwent hepatic trisegmentectomy and chemoradiation. Her course was complicated by recurrent episodes of radiation-induced gastric outlet obstruction requiring balloon dilations. She presented with right lower quadrant pain after routine upper endoscopy with pyloric dilation. A computed tomography (CT) showed isolated right-sided ischemic colitis with vascular contrast in the mesentery. Repeat CT after conservative management revealed near resolution of the ischemic changes. Perforation at the level of the pylorus is a complication of endoscopic pyloric dilation but vascular injury has never been described.

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

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.

Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation☆

Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or without pyloromyotomy and analyze its management by endoscopic pyloric dilatation. Two hundred forty-two patients underwent esophagectomy with gastric conduit from January 2002 to June 2006. Subjects were divided into two groups: Group A had no pyloromyotomy (n=83) and Group B had a pyloromyotomy (n=159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air-fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. The groups were similar except for a higher percentage of cervical anastomosis and older age (64- vs 61-year-old) in Group A. The overall incidence of gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p=0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p=0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p=0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p=0.96). Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastric outlet obstruction can be effectively managed with endoscopic pyloric dilatation. Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted.

PEPTIC PYLORIC STENOSIS

Purpose: Through the scope balloon dilationisauseful alternative to surgery in patients with peptic pyloric stenoses. However, there is a high rate of recurrence on the long term follow-up. The aim of this study is to evaluate long term results in balloon dilation associated to HP eradication. Methods: Between october 1996 and december2003, we included 36 consecutive patients (27 from our department; 32 males; mean age 46 years) with peptic pyloric stenosis. After successful dilation, patients received PPI for 1 month and HP treatment if they were infected. Endoscopy was repeated at 2, 12 months and in case of recurrence. Clinical controls were proposed every 6 month. Results: All included patients were HP positive. Dilation was successful in 89% (32/36) of cases after an average 1.9 dilatations (range: 1-7). 11% needed surgery (perforations = 2; failure of dilatation = 2). Of the 27 patients of our department, 22 had a mean follow-up time of 45 months. 36% (8/22) had recurrence of pyloric stenosis, and all of them were positive for HP. 6 of these 8 patients had a repeat endoscopic pyloric dilatation, with a positive clinical response during a 39 months follow-up. Conclusions: Balloon dilation of peptic pyloric stenosis is a safe, effective and cheap technique, even in case of recurrence. HP infection is frequent and eradication improves long terms results.

Vagotomie tronculaire par vidéothoracoscopie sans drainage gastrique. Étude prospective de 250 cas opérés au Sénégal

Aim of the study The aim of this prospective study was to report early results of videothoracoscopic truncal vagotomy in non-complicated chronic duodenal ulcers. Patients and methods From 1995 to 1998, 250 patients suffering from chronic duodenal ulcer without pyloric stenosis were operated on in the main hospital of Dakar. They underwent videothoracoscopic truncal vagotomy without gastric drainage. The quality of gastric emptying and the incidence of secondary side-effects were assessed in the postoperative course and after one and three months. Results There were two intraoperative deaths, one due to aortic wound and the other one due to a poor surveillance after premature extubation. Postoperative complications included bronchopulmonary infection ( n=9), one septic pleural effusion and one chylothorax. A postoperative gastroplegia occurred in 12 patients, which was always spontaneously regressive without endoscopic pyloric dilatation. After one month, 204 patients (82%) were classified Visik 1, and 44 (18%) classified Visik 2. An endoscopic control examination showed a healed peptic ulcer and open pylorus in all patients, and a gastric stasis present in 40 cases (16%). After three months and a new evaluation, 234 were classified Visik 1 (94%) and 14 Visik 2 (6%). Dumping syndrome was not observed in this series and the incidence of diarrhea, which was 40% after one month, decreased to 3% after three months. Conclusion The functional results of truncular vagotomy without gastric drainage were good or very good and improved with time. The quality of digestive comfort and the low frequency of side-effects are good arguments in favor of this procedure as an elective treatment of duodenal ulcers in developing countries.