Pyloric Intervention Research Articles

Controversies in the management of the pylorus among patients undergoing robotic-assisted minimally invasive esophagectomy

Bilateral truncal vagotomies are intrinsic to nearly all esophagectomies, rendering patients susceptible to delayed gastric emptying. The question of whether, how, and when to perform pyloric drainage is essential and remains controversial in the era of robotic-assisted minimally invasive esophagectomy. While a variety of pyloric intervention techniques have been described, selective endoscopic pyloromyotomy for post-esophagectomy patients with durable signs of delayed gastric emptying is an attractive option, given its low morbidity rate, particularly its low incidence of dumping.

Effect of pyloroplasty on clinical outcomes following esophagectomy.

The role of concurrent pyloroplasty with esophagectomy is unclear. Available literature on the impact of pyloroplasty during esophagectomy on complications and weight loss is varied. Data on the need for further pyloric intervention are scarce. Our study compares the clinical outcomes after esophagectomy with or without pyloroplasty and investigates the role of post-operative pyloric dilatation. Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, mortality rate, anastomotic leak, respiratory complications (Clavien-Dindo grade ≥ 3), anastomotic stricture rate, and percentage weight loss at 1 and 2 year post-operatively were evaluated. For weight analysis at 1 and 2 year post-operatively, patients were excluded if they had been diagnosed with recurrence or died prior to the 1 or 2 year timepoints. Ninety-two patients did not have a pyloroplasty, and 115 patients had a pyloroplasty. There were no complications resulting from pyloroplasty. There was no significant demographic difference between the groups except for age. Mortality rate, anastomotic leak, respiratory complications, anastomotic stricture rate, and percentage weight loss at 1 and 2 years were statistically similar between the two groups. However, 14.1% of patients without pyloroplasty required post-operative endoscopic pyloric balloon dilatation to treat respiratory complications or gastroparesis. Subgroup analysis of patients without pyloroplasty indicated that patients requiring dilatation had greater weight loss at 1 year (15.8% vs 9.4%, p = 0.02) and higher respiratory complications rate (27.3% vs 4.7%, p = 0.038). Overall results from our study that pyloroplasty during Ivor Lewis esophagectomy is safe and useful to prevent the need for post-operative pyloric dilatation.

561. COMMONALITY AND VARIATION IN PERIOPERATIVE ESOPHAGEAL CANCER MANAGEMENT IN HIGH VOLUME EUROPEAN CENTERS

Abstract Background Esophageal cancer is a leading cause of cancer related death worldwide. For patients with locally advanced, non-metastatic, esophageal cancer (EC), surgical resection remains an essential pillar. The multitude of surgical options have driven innovation, however, lack standardization and at times high-quality data-driven practices. A surgeon-level in-depth interview and questionnaire was created to understand the perioperative care pathways and intraoperative techniques used by high-volume European EC centres to gain insight into commonality and variation of current practice. Methods Eight (8) expert upper gastrointestinal surgeons were invited to participate in an in-depth interview and questionnaire. The focus included preoperative care pathways for esophageal adenocarcinoma of the distal esophagus/GE junction, technical aspects of esophageal resection (Ivor-Lewis) and postoperative pathways. The involvement of allied health, dedicated research programs, multidisciplinary cancer conference (MCC), follow up protocols and management of T4b EC was also assessed. Results The response rate was 100% (8/8). Majority of respondents indicated a country-level regionalization of EC care. The number of centres performing esophageal resection varied from 4 – >100. Average number of esophagectomies/year ranged from 60-150. All centres presented EC patients at MCC, had dedicated research programs, and participated in National and International EC databases. Chemoradiotherapy was the predominate neoadjuvant treatment for GEJ cancers. Pretreatment clinical staging varied, with all centres having different, but pre-defined, preoperative and postoperative pathways. Intraoperative techniques including conduit preparation, feeding tube use, pyloric intervention, thoracic duct ligation and anastomotic technique varied substantially. There was no consensus regarding follow up or management of T4b EC. Conclusion The perioperative pathways and technical aspects of esophageal resection shared some commonalities however also differed substantially across high-volume EC centres in Europe. Multicenter, pragmatic randomized controlled trials (RCTs) are needed to better delineate which techniques should be included as standard of care, and which should be abandoned.

In silico modelling of the effect of pyloric intervention procedures on gastric flow and emptying in a stomach with gastroparesis.

Pyloric interventions are surgical procedures employed to increase the gastric emptying rate in gastroparesis patients. In this study, we use an in silico model to investigate the consequences of pyloric intervention on gastric flow and emptying for two phenotypes of gastroparesis: antral hypomotility and decreased gastric tone. The transpyloric pressure gradient predicted by the in silico model, based on viscous fluid flow equations, is compared against in vivo measurements. Both phenotypes exhibit a similar pre-procedural emptying rate reduction, but after pyloric surgery, antral hypomotility case with preserved gastric tone shows significant improvements in emptying rates, up to 131%, accompanied by bile reflux from the duodenum into the stomach. Conversely, severely reduced gastric tone cases exhibited a post-procedural reduction in the net emptying rate due to the relatively larger bile reflux. In cases with a combination of antral hypomotility and reduced gastric tone, post-procedural improvements were observed only when both conditions were mild. Our findings highlight the pivotal role of the relative increase in pyloric orifice diameter in determining post-operative emptying rates. The study suggests a possible explanation for the selective response of patients toward these procedures and underscores the potential of in silico modelling to generate valuable insights to inform gastric surgery.

OGC P33 Comparison of the post-operative outcomes of surgical and chemical interventions on the gastric pylorus during oesophagectomy: A systematic review and meta-analysis

Abstract Background Oesophagectomy can lead to gastric dysmotility and pyloric dysfunction, causing delayed gastric emptying (DGE). DGE is associated with significant postoperative morbidity, namely aspiration pneumonia and anastomotic leak. Surgical drainage and botox injections (BI) on pylorus were described to combat DGE. Pyloric interventions however can increase risk of bile reflux, oesophagitis, dumping syndrome and pyloric leaks. Current literature showed equivocal short- and long-term outcomes of pyloric drainage procedures, with no consensus on the necessity of such procedures. We aim to evaluate the latest literature, comparing effects of different pylorus surgical drainage methods, BI and watch-and-wait approach on the pylorus during oesophagectomy Methods The OVID database was searched systematically. Articles were screened with the Rayyan software. Inclusion Criteria of articles are as follows: • RCT and comparative cohort studies (retrospective and prospective) which included any drainage methods, performed at the same time as oesophagectomy • Oesophagectomy for benign or malignant conditions • Studies of adult human subjects ≥ age of 18 years old • Studies published in English language • Studies published within the last 25 years Primary outcomes evaluated were DGE and pulmonary complication rates. A traditional pairwise meta-analysis was performed with Revman 5.4, utilizing a random effects model for analysis of the pooled outcome measures. Results Data of 3925 patients from 27 publications evaluating up to ten pyloric interventions were analyzed. Most studies were retrospective in nature (24 studies). Due to heterogeneity of reported outcomes, pooled meta-analyses were only performed on limited studies. Pooled analyses showed pyloric interventions reduced DGE rates in 19 studies and pulmonary complications in 11 studies. Relative risks (95% CI; p value) were 0.95 (0.7,1.29; p=0.74) and 0.88 (0.72,1.08; p=0.22), respectively.Figure 1:Forrest plot comparing DGE rates of Pyloric Interventions vs No Intervention Figure 2:Forrest plot comparing rates of Pulmonary Morbidity of Pyloric Interventions vs No Intervention Conclusions Our systematic review and meta-analysis did not observe statistically significant and conclusive evidence favouring pyloric drainage procedures to none. High quality comparative studies and inconsistent scrutinization of post operative outcomes were lacking. Prospectively designed RCT or propensity matched cohort studies comparing surgical pyloric drainage, BI and no intervention should be conducted to produce standardized comparison. We suggest analyzing post operative outcomes by measuring data which could be objectively recorded (DGE utilizing the latest definition, pulmonary morbidity, anastomotic leak, biliary reflux rates, radiographic or endoscopic findings etc.) combined with subjective measurement of patient symptoms, where a patient-centred questionnaire could be performed.

A comparative review of minimally invasive approaches to esophagectomy: technical considerations, variations, and outcomes

Esophageal cancer continues to rise as a public health issue, and esophagectomy remains a mainstay therapy for the disease. Surgical approaches to esophagectomy have evolved over the past few decades with the advent of laparoscopic, thoracoscopic, and robotic technologies. The aim of this review is to identify original articles and perform a comprehensive literature search to provide updates on surgical approaches and technical considerations for esophagectomy. Articles describing the surgical technique specific to robotic-assisted minimally invasive esophagectomy (RAMIE) were reviewed and included. Technical considerations reviewed were comprised of patient positioning, optimal trocar placement, dissection, indocyanine green use, kocherization, pyloric interventions, anastomotic techniques, jejunostomy tube placement, and gastric ischemic conditioning, discussing relevant outcomes for each consideration and approach. Clinical outcomes were also evaluated by comparing RAMIE to open esophagectomy and minimally invasive esophagectomy. Outcomes reviewed included lymph node harvest, intra-operative blood loss, operative times, 30-day readmission, mortality, length of stay, pulmonary complications, recurrent laryngeal nerve injury, anastomotic leak, long-term survival, and disease-free survival.

Effect of intraoperative botulinum toxin injection on delayed gastric emptying and need for endoscopic pyloric intervention following esophagectomy: a systematic review, meta-analysis, and meta-regression analysis.

The aim of this study was to evaluate the effect of intraoperative botulinum toxin (BT) injection on delayed gastric emptying (DGE) and need for endoscopic pyloric intervention (NEPI) following esophagectomy. In compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a systematic review of studies reporting the outcomes of intraoperative BT injection in patients undergoing esophagectomy for esophageal cancer was conducted. Proportion meta-analysis model was constructed to quantify the risk of the outcomes and direct comparison meta-analysis model was constructed to compare the outcomes between BT injection and no BT injection or surgical pyloroplasty. Meta-regression was modeled to evaluate the effect of variations in different covariates among the individual studies on overall summary proportions. Nine studies enrolling 1070 patients were included. Pooled analyses showed that the risks of DGE and NEPI following intraoperative BT injection were 13.3% (95% confidence interval [CI]: 7.9-18.6%) and 15.2% (95% CI: 7.9-22.5%), respectively. There was no difference between BT injection and no BT injection in terms of DGE (odds ratio [OR]: 0.57, 95% CI: 0.20-1.61, P = 0.29) and NEPI (OR: 1.73, 95% CI: 0.42-7.12, P = 0.45). Moreover, BT injection was comparable to pyloroplasty in terms of DGE (OR: 0.85, 95% CI: 0.35-2.08, P = 0.73) and NEPI (OR: 8.20, 95% CI: 0.63-105.90, P = 0.11). Meta-regression suggested that male gender was negatively associated with the risk of DGE (coefficient: -0.007, P = 0.003). In conclusion, level 2 evidence suggests that intraoperative BT injection may not improve the risk of DGE and NEPI in patients undergoing esophagectomy. The risk of DGE seems to be higher in females and in early postoperative period. High quality randomized controlled trials with robust statistical power are required for definite conclusions. The results of the current study can be used for hypothesis synthesis and power analysis in future prospective trials.

Controversies in the surgical management of esophageal adenocarcinoma.

The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the last decade. Over this same period, our understanding and treatments have been revolutionized. Just over a decade ago, the majority of patients with locally advanced esophageal cancer went directly to surgery and our overall survival was bleak. Our current strategy for locally advanced esophageal adenocarcinoma is a multi-disciplinary approach. This approach consists of chemotherapy plus or minus radiation followed by surgical resection followed by adjuvant immunotherapy with the presence of any residual disease. Therefore, now more than ever, the goals of surgery are to minimize morbidity, provide aggressive local control and allow patients to receive to quickly recover so they can receive adjuvant systemic therapy. Surgery continues to play a crucial role in the multi-disciplinary approach to EAC. This review will highlight the on-going areas of controversy in surgical treatment. These controversies are around surgical selection, perioperative decision making and the role of surgery. Specifically, there are controversies in the type of surgical approach offered. This review will discuss the benefits of minimally invasive versus open esophagectomy. The indications for gastrectomy versus esophagectomy in patients with gastroesophageal junction EAC. Further, at the time of operation, there is still debate and on-going trials addressing the addition of a pyloric intervention. Lastly, as we push the limits of systemic therapy, there are those who may not even need a surgical resection. This review will cover the most recent data on selective esophageal resection and the concerns regarding this approach.

Impact of anesthetics on pyloric characteristics measured using the EndoFLIP® system in patients with gastroparesis.

Pyloric distensibility has been reported as a predictive measure in gastroparesis. Measures can be obtained either during endoscopy under anesthesia or in unsedated patients. However, the impact of anesthetic drugs on the results of pyloric characteristics remains unknown. The objective of the present study was to determine the impact of anesthetics on pyloric characteristics measured using EndoFLIP® in patients with gastroparesis. Consecutive patients with gastroparesis from three French tertiary centers were retrospectively analyzed. Patients with a previous history of pyloric intervention were not considered for analysis. Medical records were reviewed for the potential use of anesthetic drugs during EndoFLIP® measurement. One hundred twenty-five patients were included in the present study [median age: 55.0 years (43.0-66.0)]. Thirty-four patients (27.2%) had pyloric assessment without general anesthesia and 91 patients (72.8%) with general anesthesia. Pyloric pressure at 40 mL of distension was higher in patients with general anesthesia in comparison with patients without general anesthesia [18.7 (13.0-25.6) mmHg vs. 15.4 (11.9-20.7) mmHg; p = 0.044)]. In multivariate analysis, suxamethonium chloride administration was associated with decreased pyloric distensibility (OR: 3.9; 95% CI: 1.3-11.4; p = 0.013) while ephedrine was rather associated with increased pyloric distensibility (OR: 0.3; 95% CI: 0.1-0.9; p = 0.036). This study is the first to have found an impact of general anesthesia on pyloric measurement using the EndoFLIP®. Therefore, further studies are needed to confirm these findings, if possible, prospective studies.

Pyloroplasty Reduces the Need for Pyloric Dilatation After Esophagectomy

Background: Delayed gastric conduit emptying (DGCE) is a recognized complication of esophagectomy which can lead to prolonged vomiting, aspiration, and reduced oral intake postoperatively. To minimize the risk of DGCE, some advocate the use of pyloroplasty, however the practice is varied and controversial. The aim of this study is to investigate the effect of pyloroplasty on DGCE in esophagectomy patients. Methods: Consecutive patients that underwent an esophagectomy for esophageal cancer from September 2011 to December 2020 were identified from a prospectively maintained departmental cancer database at our institution. The primary outcome measured was the need for pyloric intervention following esophagectomy. Secondary outcomes included cardiac complications, pulmonary complications, anastomotic leaks, and chyle leaks. For those who had contrast swallow tests done prior to discharge from the index admission, dilated conduit and delayed gastric emptying were also investigated. Results: Of 458 patients included in the study, 77(17%) underwent pyloroplasty. Of the 381 patients who underwent esophagectomy without pyloroplasty, 44 (12%) of these patients later required at least one pyloric dilatation. None of the patients who underwent pyloroplasty later required pyloric dilatation. On multivariate analysis, younger age, respiratory complications after esophagectomy and pyloroplasty were significant predictors of the need for pyloric dilatation. Pyloroplasty was not significantly related to dilated conduit or delayed emptying on contrast swallow with P value of 0.979 and 0.147, respectively. Conclusions: Pyloroplasty reduces the need for pyloric dilatation postoperatively. However, further research is required to investigate the nature of this relationship, specifically in terms of contrast swallow.

Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis.

Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure. A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention. Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29). Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.

Comprehensive characterization of antral and pyloric contractions by high resolution manometry: applied physiology in suspected gastroparesis.

Delayed gastric emptying may result from diverse pathophysiological mechanisms including antral hypomotility and pylorospasm. With increasing use of gastric peroral endoscopic myotomy and preliminary evidence of efficacy, our aim was to assess the motor functions of the distal antrum and pylorus in patients with symptoms of gastroparesis using high-resolution antropyloroduodenal manometry (HR-ADM). Sixteen patients with symptoms suggestive of gastroparesis underwent HR-ADM with 13 sensors, 1 cm apart, placed across the antropyloroduodenal (APD) junction and 2 sensors, 10 cm apart, in descending and distal duodenum. The 1-h postprandial motility was quantitated as contraction frequency/minute, average amplitude, and motility index (MI). Six healthy volunteers served as controls. In the patient group, the HR-ADM identified postprandial antral hypomotility, isolated pyloric pressure waves, and tonic elevation of baseline pressure in pylorus. Patients had significantly reduced frequency of the full-hour postprandial antral contractions/minute compared with healthy volunteers [1.52 (0.97, 1.67) vs. 2.04 (1.70, 2.67), P = 0.005], as well as reduced MI [9.65 (8.29, 10.31) vs. 11.04 (10.65, 11.63), P = 0.002]. The average contraction amplitude was numerically, but not significantly reduced [51.9 (21.9, 74.9) vs. 73.0 (59.8, 82.7), P = 0.14]. Bland-Altman plots showed similar distribution of antral contraction frequency and MI during the first and second postprandial 30-min periods for both patients and controls. High-resolution ADM can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions. This technique shows promise to provide guidance for the selection of optimal treatment of patients with gastroparesis.NEW & NOTEWORTHY Current selection of different treatments for patients with gastroparesis is empiric or based on trial and error, though pyloric distensibility and diameter may predict response to pyloric interventions. High-resolution antropyloroduodenal manometry (HR-ADM) can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions in patients with suspected gastroparesis. HR-ADM shows promise to provide guidance for selection and individualization of treatments such as prokinetic agents or pyloric interventions for patients with gastroparesis based on documented pathophysiology.

P-OGC12 Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes

Abstract Background Over 1,500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation. Methods An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data Results Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions. Conclusions Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

P-OGC73 Effect of pyloroplasty on the need for endoscopic intervention for delayed gastric emptying post oesophagectomy

Abstract Background Delayed gastric emptying (DGE) is a common complication following oesophagectomy, affecting 15-39% of patients. Controversy remains regarding the role of pyloric drainage procedures during oesophagectomy with gastric conduit reconstruction in reducing DGE. This study investigated the effect of pyloroplasty at the time of oesophagectomy on the need for endoscopic pyloric intervention post-operatively. Methods We performed a retrospective analysis of all oesophagectomies performed in a single tertiary centre over a 10-year study period between 1 January 2010 and 31 December 2019. Electronic records were reviewed to analyse patient demographics, operative details and post-operative outcomes, as well as the need for endoscopic procedures after surgery. Patients were dichotomized into two groups, with those who had pyloroplasty performed at oesophagectomy compared to those who did not. Patients who died ≤30 days after oesophagectomy were excluded from analysis. Patients were followed up for a median of 32 months (IQR 19-60). Results 298 patients were eligible for the study, of whom 80/298 (26.8%) had a pyloroplasty performed. Demographics were evenly matched between the two groups. Patients undergoing Ivor-Lewis oesophagectomy were significantly more likely to have had pyloroplasty performed (90.0% vs. 24.3%; p < 0.001). Pyloroplasty had no significant effect on post-operative complication rates, ICU admission, need for re-operation or length of hospital stay. Patients without a pyloroplasty were significantly more likely to require endoscopic pyloric balloon dilatation (43.1% vs. 12.4%, p < 0.001) or pyloric botox injection (12.4% vs. 3.8%, p = 0.029) after oesophagectomy. Conclusions In this study, patients who had a pyloroplasty at the time of oesophagectomy were significantly less likely to require endoscopic pyloric balloon dilatation and/or pyloric botox injection post-operatively. This has significant long-term implications for both patients’ quality of life post-operatively and demands on over-stretched endoscopic services.

Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes

BackgroundOver 1500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation. Material and methodsAn electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data. ResultsMost centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions. ConclusionsPyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

272 Effectiveness of Intraoperative Botulinum Toxin Injection on Gastric Emptying During Oesophagectomy: A Systematic Review

Abstract Introduction Oesophagectomy is the standard of care for resectable oesophageal carcinoma and remains pivotal for curative treatment. Pull-up with gastric conduit remains the most common reconstruction. Delayed gastric emptying (DGE) is a recognised complication and may lead to delayed postoperative recovery and prolonged hospital stay. Botulinum Toxin BTA has been used to relax the hypertonic pylorus intraoperatively and improve DGE. The aim of this review was to assess the efficacy of intraoperative BTA on gastric emptying and the need for postoperative endoscopic pyloric intervention (EPI). Method Systematic review of literature was conducted using electronic database searched up to October 2020 including Cochrane Library, Medline, Embase and Goggle Scholars to identify relevant studies. Data was extracted and critically appraised by two independent authors. Results Eleven studies were included for systematic review with 1800 patients assigned to either BTA, pyloroplasty, pyloromyotomy, or no-intervention. Ten were observational studies and one was a randomised experimental study. Only one study reported a statistically significant benefit of BTA on early DGE (Day 4, 59%, P < 0.001). Three studies reported higher rates of postoperative EPI when chemical pyloroplasty was used. Length of Hospital stay was higher for patients who had BTA compared to other techniques in three studies. Conclusions This systematic review did not demonstrate any significant benefit of intraoperative BTA on gastric emptying on the long term. The rate of endoscopic pyloric intervention was higher in these patients as reported by some studies. Further studies are required to investigate the outcome of chemical pyloroplasty during esophagectomy.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

712 NASOGASTRIC TUBE DRAINAGE AND PYLORIC INTERVENTIONS FOR DELAYED GASTRIC EMPTYING AFTER OESOPHAGEAL RESECTION: A NATIONAL ANALYSIS OF SPECIALIST UK CENTRES

Abstract Nasogastric tubes (NGTs) and pyloric intervention in oesophagectomy are used to lessen the impact of gastric tube distention and delayed gastric emptying. However, their utility remains unclear, with mixed evidence and some studies suggesting they may increase morbidity and patient discomfort. We performed a national survey of tertiary oesophageal surgery centres to assess current practice and surgeon equipoise for a potential prospective trial. Methods An electronic survey was distributed to all oesophageal resection centres in England, Wales and Scotland. Included questions assessed centres’ use of NGTs, current practice for removal and dietary progression, and use of pyloric interventions. Variations in practice were assessed, and compared to nationally reported annual centre volumes and length of stay. Results Seventy-nine percent (31/39) of all centres responded to the survey. All centres reported routinely using an NGT. Most centres (19/31, 61%) did not perform pyloric intervention or routine post-operative radiological assessment (22/31, 71%). Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different practice criteria. There were no trends for practices when comparing high vs low volume centres, or above vs at-or-below median length of stay. 21/31 (68%) centres were willing to take part in a trial to assess NGT use and pyloric interventions. Conclusion NGTs remain standard practice despite mixed evidence for their efficacy and an absence of standardisation in their use. Use of pyloric intervention varies widely, with no clear link to outcomes. Surgeons recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

712 Gastric Emptying Procedure in Oesophagectomy: Meta-Analysis of Surgical Pyloroplasty vs Nil Intervention

Abstract Introduction Surgical pyloroplasty is often performed to reduce the rate of delayed gastric emptying. However, the clinical significance of this is not clear. The aim of this meta-analysis is to compare the rates of delayed gastric emptying, anastomotic leak, pulmonary complications, need for further pyloric intervention, and mortality in those patients undergoing pyloroplasty following oesophagectomy and those who do not. Method Relevant Randomised Control Trials and Cohort Studies were identified. The first group had no drainage procedure following oesophagectomy, whereas the second group underwent a drainage procedure (pyloroplasty). A random effects meta-analysis model was used to compare the outcomes. Results 12 papers were utilised in the analysis, comprising a total 2567 patients. No significant differences were found between the two groups with regards to delayed gastric emptying (RR 0.87 [95% CI: 0.47 – 1.62], p = 0.66), anastomotic leak (RR 1.20 [95% CI: 0.82 – 1.74], p = 0.34), pulmonary complications (RR 1.04 [95% CI: 0.79 – 1.37], p = 0.79), need for further pyloric intervention (RR 1.44 [95% CI: 0.87 – 2.37], p = 0.16), and mortality (RR 1.18 [95% CI: 0.43 – 3.23], p = 0.75). Conclusions Surgical pyloric drainage procedures do not improve outcomes for patients undergoing oesophagectomy, nor does omitting the procedure worsens the outcomes.

Relationship of motor mechanisms to gastroparesis symptoms: toward individualized treatment.

Following a classical paper by Dr. Keith A. Kelly published in this journal, and over the past 40 years, there has been increased understanding of the functions of different regions of the stomach, specifically the fundus, antrum, and pylorus. Several of the important physiological principles were based on in vivo animal studies that led to the appreciation of regional function and control mechanisms. These include the roles of the extrinsic parasympathetic vagal innervation, the gastric enteric nervous system and electrical syncytium consisting of pacemaker cells and smooth muscle cells, and duodenogastric reflexes providing feedback regulation following the arrival of food and hydrogen ions stimulating the release of hormones and vagal afferent mechanisms that inhibit gastric motility and stimulate pyloric contractility. Further insights on the role of regional motor functions in gastric emptying were obtained from observations in patients following diverse gastric surgeries or bariatric procedures, including fundoplication, Billroth I and sleeve gastrectomy, and sleeve gastroplasty. Antropyloroduodenal manometry and measurements of pyloric diameter and distensibility index provided important assessments of the role of antral hypomotility and pylorospasm, and these constitute specific targets for individualized treatment of patients with gastroparesis. Moreover, in patients with upper gastrointestinal symptoms suggestive of gastroparesis, the availability of measurements of gastric accommodation and pharmacological agents to reduce gastric sensitivity or enhance gastric accommodation provide additional specific targets for individualized treatment. It is anticipated that, in the future, such physiological measurements will be applied in patients to optimize choice of therapy, possibly including identifying the best candidate for pyloric interventions.