Pyloroplasty and pyloromyotomy in gastric replacement of the esophagus after esophagectomy: A randomized controlled trial

Abstract

BACKGROUND: Drainage methods for the gastric conduit after esophagectomy for carcinoma have been controversial. STUDY DESIGN: In a randomized controlled trial, 92 patients with esophageal carcinoma were randomized to have pyloroplasty or pyloromyotomy as a drainage procedure for the gastric conduit used for esophageal replacement. Only patients who underwent Lewis- Tanner operation or esophagogastrectomy and who had normal pyloroduodenal regions were included. RESULTS: The mean postoperative daily nasogastric output (SEM) were 164 mL (17 mL) in the pyloroplasty group and 179 mL (21 mL) in the pyloromyotomy group (p=not significant). No leakage occurred at the pyloroduodenal region in either group. In both groups, the anastomotic leakage rate was 2 percent, and the in-hospital mortality rate was 7 percent. No significant difference was found in postoperative morbidity and mortality. Gastric outlet obstruction developed in only two patients who underwent pyloromyotomy, and both required reexploration. One died of malignant obstruction of the gastric outlet and aspiration pneumonia. Scintigraphy performed 6 months after operation showed that the median half-life (interquartile range) for gastric emptying was 19 minutes (10 to 24 minutes) in the pyloroplasty group and 8 minutes (5 to 19 minutes) in the pyloromyotomy group (p=0.04). Long-term follow-up up to 5 years, however, did not reveal significant differences between the two groups in the type and quantity of food consumed. The incidence of other symptoms such as regurgitation, diarrhea, bile reflux, and dumping, also was no different. CONCLUSIONS: Pyloroplasty and pyloromyotomy were effective and safe drainage procedures for the gastric conduit used for esophageal replacement. The choice depends on the preference and experience of the surgeon. Most patients adapted to their new conduit with time.