Management of delayed gastric emptying after esophagectomy with endoscopic balloon dilatation of the pylorus.

BACKGROUND: This study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit.

METHODS: A total of 436 patients underwent esophagectomy with gastric conduit from 2002 to 2009. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter, anastomotic location, and mediastinal route were variable. Gastric outlet obstruction (GOO) was strictly defined to include patients with clinical and radiographic delayed gastric emptying requiring intervention.

RESULTS: Gastric outlet obstruction was found in 22% (98 of 436) of patients who underwent esophagectomy. Pyloromytomy was performed on 52% (51 of 98) of these patients and employed in 41% (179 of 436) of patients in the entire cohort. GOO was present in 28% (51 of 179) of patients who underwent a pyloric drainage procedure compared with 18% (47 of 257) of patients with no pyloric intervention (p = 0.01). Endoscopic balloon dilatation of the pylorus was used to treat 39% (38 of 98) of patients with delayed gastric emptying yielding a 95% (36 of 98) success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators (range,10 to 20 mm). The remaining patients were treated conservatively with prokinetics, nasogastric drainage, or observation. Nasogastric drainage was employed for 7.4 ± 4.4 days in patients with GOO and 6.8 ± 4.0 days in asymptomatic patients (p = 0.15). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. There was a significant difference in postoperative pneumonia (18.4% vs 10.6%, p = 0.05) and median length of hospital stay (12 ± 16 vs 10 ± 9 days, p < 0.0001) in patients with GOO versus normal emptying.

CONCLUSIONS: Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.