Pyloric Drainage Research Articles

Ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum in a newborn with pyloric atresia, annular pancreas and congenital short bowel syndrome

We report a newborn with bilious vomiting and the rare combination of pyloric atresia, annular pancreas and ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum. Radiologic, sonographic and percutaneous transhepatic transcholecystic cholangiographic (PTTC) findings, with surgical correlation, are presented.

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.”

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

Reply to the letter by L. Bonavina regarding our article “Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction”

We would like to thank Prof. Bonavina for his interest and comments on our paper. Our paper deals with the effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction. Omitting pyloric drainage is not only safe after esophagectomy, it also avoids bile reflux and esophagitis in the long term as gastric outlet obstruction due to pyloric spasm only represents a transient phenomena that either spontaneously disappears or can be successfully treated by endoscopic intervention [1, 2]. Alternatively, additional intraoperative mechanical dilatation of the pylorus has been shown to be as effective and safe [3]. However, until now, the pathomechanism of the spontaneously declining pylorospasm has not been completely understood. We agree that the size of the gastric conduit might contribute to a faster passage due to an increased wall stress, e.g., by inducing peristaltic waves, which possibly reduce pylorus spasm respectively lead to a reflectory opening of the pylorus. Therefore, in our institution, we always create a 4to 5-cm wide tubularized stomach, and the anastomosis is placed above the arch of the azygos vein to reduce reflux esophagitis. It is interesting to observe that by laparoscopic conditioning of the stomach, the incidence of clinically significant gastric outlet obstruction seems to be further reduced (3.6 vs 6.1% [4]). On the other hand, it is also surprising that anastomotic leakage rate seems to be not reduced by ischemic conditioning of the stomach. Theoretically, after partial devascularization, the gastric conduit should recover, and gastric tissue perfusion should be improved prior to pull-up and anastomosis to the esophagus resulting in better prerequisites for anastomotic healing. Perhaps, the size of the leakage and severity of symptoms can be reduced by ischemic conditioning as all patients with leakages of the esophagogastrostomy (6.1%) had only minor clinical symptoms, and endoscopy showed very well-vascularized resection lines of the esophagus and stomach [4]. However, information whether ischemic conditioning of the stomach before esophagectomy affects local tumor recurrence, and therefore, long-term survival would be desirable. Further controlled randomized studies on these topics are necessary and worthwhile for patients with esophageal carcinoma, as normal gastrointestinal function after esophagectomy is still rare and improving the quality of life represents one of the main goals in these patients [5]. Langenbecks Arch Surg (2008) 393:119–120 DOI 10.1007/s00423-007-0241-y

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

Combined pedicled antropyloroplasty and gastric pull-up reconstruction for corrosive esophagogastric stricture

A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy

Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage. Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study. No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet. Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.

What Is the Difference between Proximal and Total Gastrectomy Regarding Postoperative Bile Reflux into the Oesophagus?

Background: Tumours of the oesophagogastric junction and the gastric cardia can be treated either with proximal or with total gastrectomy. Reflux of bile and other duodenal contents into the oesophagus following proximal gastrectomy has generally been considered worse than reflux after total gastrectomy. The aim of the present study was to test this assumption given that there is limited literature regarding objective evaluation of the postoperative duodeno-oesophageal reflux. Patients and Methods: We carried out bilirubin monitoring with the ambulatory spectrophotometer Bilitec 2000 in two groups of patients and in one group of healthy volunteers matched in age and sex. The proximal gastrectomy group consisted of 8 patients who underwent proximal gastrectomy and an end-to-side oesophagogastrostomy without pyloric drainage procedure. The total gastrectomy group consisted of 11 patients who underwent total gastrectomy and Roux-en-Y reconstruction with a 50-cm-long jejunal limb. The control group consisted of 8 healthy volunteers. In all cases, an absorption value of 0.14 was used as the threshold for reflux episodes. Results: The median fraction of time that bilirubin absorbance was >0.14 in the proximal versus total gastrectomy group was 47.4 and 13.4%, respectively (p = 0.02). The difference between the two groups was significant in the supine position (p = 0.03), whilst the upright position, meal and postprandial periods were not found to have significant difference. Likewise, no significant difference was found in the number of reflux episodes. The median fraction of time in the proximal gastrectomy group compared with controls was 47.4 versus 3.95% (p < 0.001), whilst in the total gastrectomy group compared with controls, itwas 13.4 versus 3.95% (p > 0.05). The number of reflux episodes in the proximal gastrectomy group compared with controls was 74 versus 21 (p = 0.02), whilst in the total gastrectomy group compared with controls, it was 103 versus 21 (p > 0.05). Conclusions: Total gastrectomy with Roux-en-Y reconstruction reduces the time of oesophageal exposure to duodenal juices as compared with proximal gastrectomy. This effect seems to be more prominent in the supine position.

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy. One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed. Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis. Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.

Atrial fibrillation after off-pump versus on-pump: Are we not missing a common pathophysiological pathway?

We read with interest Junemann-Ramirez and colleagues’ article [1] on esophagogastric anastomotic leaks and their analysis of predictive factors, management and survival. We agree with the authors that esophagogastric anastomotic leaks are the most devastating of complications after esophageal resection and that they carry high morbidity and mortality rates. The choice of surgical procedure has a lot to do with the ultimate outcome of the patient. We feel that the consequences of an anastomotic leak are far worse with an intrathoracic anastomosis compared with a neck anastomosis. The Ivor Lewis esophagectomy has neither the advantages of a transhiatal esophagectomy (in avoiding a thoracotomy) nor does it have the advantages of a transthoracic (three-hole) total esophagectomy (where a neck anastomosis avoids the morbidity of mediastinitis in case of a leak). A three-hole esophagectomy also enables radical supracarinal mediastinal lymphadenectomy. The authors’ conclusions that patients treated conservatively fared better than those who underwent surgical intervention could clearly be explained by a selection bias as it is likely that clinically stable patients would have been treated conservatively and sicker patients with mediastinitis would have been reoperated. We also fail to understand how a pyloric drainage procedure could reduce anastomotic leaks—decompression of the gastric tube could easily and effectively be achieved by nasogastric tube decompression. In our unit (we perform an average of 160 esophagectomies a year), we perform a three-hole total esophagectomy in all patients with a neck anastomosis, but do not perform a formal pyloric drainage procedure. None of the leaks we encountered could be explained by non-performance of a gastric drainage procedure. Most true anastomotic leaks in our unit are managed conservatively as the leak gets localized in the neck with no signs of mediastinitis. Gastric tube necrosis or ischemia, on the other hand, are managed aggressively by immediate surgical reoperation with disconnection of the anastomosis with reconstruction by a coloplasty as an interval surgery [2]. Needless to state, the latter group fare worse than the former.

Management of esophagogastric anastomotic leaks☆

We read with interest Junemann-Ramirez and colleagues’ article [1] on esophagogastric anastomotic leaks and their analysis of predictive factors, management and survival. We agree with the authors that esophagogastric anastomotic leaks are the most devastating of complications after esophageal resection and that they carry high morbidity and mortality rates. The choice of surgical procedure has a lot to do with the ultimate outcome of the patient. We feel that the consequences of an anastomotic leak are far worse with an intrathoracic anastomosis compared with a neck anastomosis. The Ivor Lewis esophagectomy has neither the advantages of a transhiatal esophagectomy (in avoiding a thoracotomy) nor does it have the advantages of a transthoracic (three-hole) total esophagectomy (where a neck anastomosis avoids the morbidity of mediastinitis in case of a leak). A three-hole esophagectomy also enables radical supracarinal mediastinal lymphadenectomy. The authors’ conclusions that patients treated conservatively fared better than those who underwent surgical intervention could clearly be explained by a selection bias as it is likely that clinically stable patients would have been treated conservatively and sicker patients with mediastinitis would have been reoperated. We also fail to understand how a pyloric drainage procedure could reduce anastomotic leaks—decompression of the gastric tube could easily and effectively be achieved by nasogastric tube decompression. In our unit (we perform an average of 160 esophagectomies a year), we perform a three-hole total esophagectomy in all patients with a neck anastomosis, but do not perform a formal pyloric drainage procedure. None of the leaks we encountered could be explained by non-performance of a gastric drainage procedure. Most true anastomotic leaks in our unit are managed conservatively as the leak gets localized in the neck with no signs of mediastinitis. Gastric tube necrosis or ischemia, on the other hand, are managed aggressively by immediate surgical reoperation with disconnection of the anastomosis with reconstruction by a coloplasty as an interval surgery [2]. Needless to state, the latter group fare worse than the former.

Reflux after oesophagectomy

Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it. A Medline search using the terms 'gastro-oesophageal reflux', 'oesophagectomy' and 'antireflux surgery' was conducted. Additional references and search pathways were sourced from the bibliographies of articles located. Reflux after oesophagectomy is a significant problem, with both clinical and pathological consequences. Simple measures to facilitate gastric emptying, such as creating a gastric tube, performing a pyloric drainage procedure and using gastric motility agents, may produce a reduction in symptoms but do not alone control reflux itself. A variety of surgical reconstructions have been used, many of which are either difficult to fashion or not suitable when a radical resection has been performed. A modified fundoplication at the anastomosis seems to be the simplest technique and may be relatively effective in controlling symptoms. The impact of strategies to reduce reflux on quality of life and on pathological sequelae of reflux in the oesophageal remnant remains to be evaluated.

Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: A randomized clinical trial

Delayed gastric emptying after esophagogastrectomy can pose a significant early postoperative problem. Because erythromycin, which stimulates the gastric antral and duodenal motilin receptor, has been shown to significantly increase gastric emptying in patients with diabetic gastroparesis, we decided to evaluate its effect on gastric emptying after esophagogastrectomy. Methods: Twenty-four patients (18 men and six women, age range 41 to 79 years, median 66 years) were randomized to receive either erythromycin lactobionate (200 mg in 50 ml normal saline solution intravenously) ( n = 13) or placebo (50 ml normal saline solution intravenously ( n = 11) 11 days after esophagogastrectomy (with pyloric drainage procedure). After erythromycin or placebo had been infused over a 15-minute period, patients ingested a solid meal (scrambled egg with bread) labeled with technetium 99m sulfur colloid (500 μCi) over approximately 15 minutes. Dynamic images of the stomach were then acquired over 90 minutes in the supine position by gamma imaging. Results were expressed as percentage of counts retained in the stomach (percent gastric retention) over time. Results: There were no side effects of erythromycin. In the placebo group, the mean percent of radiolabeled meal retained in the stomach after 90 minutes was 88%, which was significantly greater than in the erythromycin group, 37% ( p < 0.001). In addition, analysis of covariance demonstrated that the rate of gastric emptying (slope of the line) was significantly greater in the erythromycin-treated group than in the placebo group ( p < 0.0001). Conclusion: Early satiety after esophagogastrectomy may be due to delayed gastric emptying and not due to a decrease in the gastric reservoir. Intravenous erythromycin significantly improves gastric emptying in patients after esophagogastrectomy by stimulating gastric motility. (J T HORAC C ARDIOVASC S URG 1996;111:649-54)

Contribution of gastrin to cysteamine-induced gastric acid secretion in rats

The role of circulating gastrin in cysteamine induced gastric acid secretion was examined in conscious male Wistar rats, provided with a portal vein catheter, a jugular vein catheter and a pyloric drainage tube. Intravenous infusion of 0.3 nmol/kg.30 min of gastrin 17-I resulted in serum gastrin concentrations of 1138±151 pg/ml and gastric acid secretion of 104±36 μmol H +/kg.30 min. this acid response was abolished by intravenous injection of 60 μl of a gastrin-antiserum, indicating the efficacy of immunoneutralization with this antiserum in vivo. Intravenous bolus administration of 125 mg/kg of cysteamine induced increases in serum gastrin concentration (864±96 pg/ml) and gastric acid outputs (107±27 μmolH +/kg.30 min) not significantly different from the gastrin 17-I infusion experiments. Gastrin antiserum abolished cysteamine-induced gastric acid secretion, indicating that gastric acid secretion induced by 125 mg/kg of cysteamine is largely mediated by circulating gastrin in rats.

Vagotomy and pyloric drainage for chronic duodenal ulcer. Long-term results.

THERE IS no general agreement as to the operation of choice for chronic duodenal ulcer. While feeling that no operation can be used for every patient, it has been routine practice for many years in Doctor R. L. Holt's surgical unit at Manchester Royal Infirmary, England, to treat most chronic duodenal ulcers by the operation of vagotomy and pylorectomy. In pylorectomy, a small lozenge is excised from the anterior aspect of the pyloric sphincter and adjacent stomach and duodenum and the defect repaired transversely. In our opinion, there can be little difference functionally between this and the Heineke-Mikulicz type of pyloroplasty and the operation should be considered a type of pyloroplasty. No attempt was made at selective vagotomy in any of these operations. In order to assess the use of vagotomy and a pyloric drainage procedure in the surgical treatment of duodenal ulcer it is important to establish