Pyloric Drainage and Gastroparesis

A recent study titled “Does pyloric drainage have a role in the era of minimally invasive esophagectomy?” and published in Surgical Endoscopy journal, caught my attention. The authors retrospectively analyzed 283 patients undergoing minimally invasive esophagectomy in a single institution. Almost half the patients underwent pyloric drainage (53 with botulinum injection and 73 surgical). Pyloromyotomy or pyloroplasty has historically been performed to prevent delayed gastric emptying following vagal nerve transection during esophagectomy. Gastric stasis results in nausea and vomiting, increase the risk of aspiration pneumonia, and anastomotic leak.

The authors, however, found no difference in the 90-day post-operative complication rate between patients with and without pyloric drainage. Furthermore, at 6 and 12 months after surgery, patients who received botulinum injection or surgical drainage had significantly more symptoms than no drainage and higher need for pyloric dilation.

I like this study because it highlights the inefficiency of stomach drainage procedures like pyloroplasty for treatment of delayed gastric emptying and gastroparesis. One would assume that in the setting of vagal nerve injury delayed pylorus hypertonicity is the underlying cause of delayed gastric emptying. Consequently, a pyloroplasty would promote gastric emptying and alleviate symptoms. This study, however, and several others show the opposite. Gastroparesis has a number of etiologies and varying pathophysiology. However, if pyloroplasty is not an effective gastroparesis treatment in the setting of vagal nerve injury, it not likely to be work in other settings for refractory gastroparesis. A number of studies have been published over the past few years about the effectiveness of endoscopic pyloroplasty (G-POEM) for treatment of medically refractory gastroparesis. I seriously doubt these results and I advocate the use of antrum preserving longitudinal gastrectomy (modified sleeve gastrectomy) to promote gastric emptying as described in previous blogs.