Comparison between Finger Bougie of the Pylorus and Pyloroplasty or Pyloromyotomy in Gastric Pull-up Esophageal Surgery

Document Type : Research Paper

Authors

Abstract

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ntroduction: In gastric pull-up esophageal surgery, functional obstruction of the pylorus is seen in almost 20% of patients. The purpose of this study was launching finger bougie of pylorus instead of traditional pyloroplasty or pyloromyotomy.
Materials and Methods:This descriptive study carried out from 2002 to 2004 on patients, admitted to the Department of General Surgery of Imam Reza Hospital, Mashhad. Of 58 patients with esophageal cancer, who underwent gastric pull-up esophageal surgery, pyloroplasty or pyloromyotomy was randomly performed on 31 cases (group A), and finger bougie of pylorus (group B) on 24 patients. On the 9th day postoperatively static function of pylorus was evaluated with gastric emptying study. Based on emptying time of the stomach, patients were divided into normal, delayed drainage and complete obstruction groups.Using a questionnaire, individual characteristics, surgical outcome and results of gastric emptying scan were recorded and analyzed by descriptive statistics, frequency distribution tables, Chi-2 and Chi- Square tests.
Results: Of patients, 58 with average age of 58 years old were evaluated from these. 40 cases (69%) were male and 18 cases (31%) were female. Pyloric operations were finger bougie in 31 cases (53/4%), pyloromyotomy in 24 cases (42/4%), and pyloroplasty in 2 cases (3/4%). In 1 case (1/7%) pylorus was intact.Complications were, wound infections in 8 patients (13/8%), cervical fistula in 2 (3.4%) thoracic fistula in 1 (1.7%), chylothorax in 3 patients and tracheal injury in 1 patient. Gastric emptying time was measured in 53 patients with TC99 scanning. The result was normal in 44 cases (75/9%), delayed in 8 cases (13/8%), and gastric outlet obstruction in 1 (1/7%).
Conclusion: Although transhiatal esophagectomy is considered as a palliative procedure, some surgeons prescribe it for all stages of the disease. Most of tracheal injuries are in membranous portion. In small tearing, conservative management with bypassing the site of injury by endotracheal or tracheostomy tube was recommended. Surgery is suggested in large tear or failure of conservative therapy. The first recommendation for fistula in cervical anastomosis is conservative. Early surgery is suggested in complete disruption, non responsive patient after 3 weeks, and intra thoracic fistula. In the present study the results of gastric emptying test in group A (finger bougie of pylorus) and group B (pyloromyotomy or pyloroplasty) were compared. Finger bougie of pylorus in gastric pull-up surgery is preferred and suggested.

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1- Charles B, Dana K, timothy R, David L, John G, Stomach Daniel, T Demopsy, Schwartzs. Principle of Surgery. Mc
Graw Hill; 2005. 961-2.
2- Townsend, Beauchamp, Evers, Mattox. Esophagus. In: Joseph BZ, Carl S, Manoop S. Sabiston textbook of surgery.
Elsevier; 2004. 1129-37.
3- Barbier P, Muller K, Wagner H. Esophageal carcinoma: surgery using transhiatal esophagectomy without
thoracotomy. Schweiz Med Wochenschr Supp 1985; 19: 9-15.
4- Gertsch P, Vauthey JN, Lustenberger AA. Long term results of transhiatal esophagectomy for esophageal carcinoma.
A multivariate analysis of prognostic factors. Cancer 1993 Oct 15; (8): 2312-9.
5- Ullah R, Bailie N, Kinsella J, Ankin et al. Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and
cervical oesophageal squamous cell carcinoma. J laryngol and otol. 2002 Oct.; 116:825-30.
6- Cowling MG, Goh PY, Mason RC. Self-expanding metallic stent in management of pyloric dysfunction after gastric
pull-up operations. Eur Radiol 1999; 9:1123-5.
7- Kauer WK, Stein HJ, Bartels H, Siewert JR. Interatracheal long-term PH monitoring: a new method to evaluate
episodes of silent acid aspiration in patients after esophagectomy and gastric pull-up. J Gastrointest Surg 2003 Jul-Aug;
7(5):599-602.
8- Johnsson J, Johnsson F, Groshen S. Pharyngeal reflux after gastric pull-up esophagectomy with neck and chest
anastomosis. J thoracic Cardiovasc Surg 1999 Dec; 118(6):1293-300.
9- Zieren HU, Muller JM, Jacobi CA. Should a pyloroplasty be carried out in stomach transposition after subtotal
esophagectomy with esophagogastric anastomosis at he neck? Aprospective randomized study. Chirurg 1995 Apr;
66(4):319-25.
10- Lee YM, Law S, Chu KM, Wong J. Pyloroplasty in gastric remnant of esophagus after esophagectomy: one-layer or
two layer technique? Dis Esophagus 2000; 13(3):203-6.
11- Nakane Y, Michiura T, Inoue K, Sato M. Role of pyloroplasty after proximal gastrectomy for cancer.
Hepatogastroenterol 2004 Nov-Dec; 51(60):1867-71.
12- Valanovich V. Esophagogastrectomy without pyloroplasty. Dis Esophagus 2003; 16(3):243-5.
13- Johnsson J, Sloth M, Baje M, Walther B. Radioisotop evaluation of the esophageal remnant and the gastric conduit
after gastric pull-up esophagectomy. Surgery. 1999 Mar; 125(3):297-303.
14- Heitmiller RF, Gillinoy AM, Kafoneck D. Transthoracic percutaneous endoscopic gastrostomy (PEG) after
esophagectomy and gastric pull-up. Surg Laparosc Endosc 1997 Aug; 6(4):351-3.
15- Law S, Cheung MC, Fork M, Chu KM, Wong J. Pyloroplasty and pyloromyotomy in gastric replacement of the
esophagus after esophagectomy: a randomized controlled trial. J Am Coll Surg 1997 Jun; 184(6):630-6.
16- James EC, Ridella PJ, Fedde CW, Anderson CK. Gastric emptying. A comparison of the Heineke-Mikulicz and
Finney pyloroplasties with the Ramstedt pyloromyotomy. Arch Surg 1981 Jul; 116(7):907-9. 
17- Kobayashi A, Lde H, Eguchi R, Nakamura T. The efficacy of pyloroplasty affecting to oral-intake quality of life
using reconstruction with gastric tube post esophagectomy. Nippon Kyobu Geka Gakkai Zasshi 1996 Jun; 44(6):770-8.
18- Andican A, Perek S, Ozcelik MF, Perek A. Transhiatal esophagectomy for esophageal carcinoma in turkey: with
special reference to respiratory function. Surg Today 1993; 23(11):960-3.
19- Urschel JD, Blewett CJ, Young JE, Miller JD. Pyloric drainage (pyloroplasty) or no drainage in gastric
reconstruction after esophagectomy: a meta-analysis of randomized controlled trials. Dig Surg 2002; 19(3):160-4.
20- Finger bougie method compared with pyloroplasty in the gastric replacement of esophagus. Surg Today 1999;
29(2):107-10.
21- Turner GG. Carcinoma of the oesophagus: The question of its treatment by surgery. Lancet 1936; 1:130-4.
22- Ong GB, Lee TC. Pharyngogastric anastomosis after oesophagectomy for carcinoma of the hypopharynx and
cervical esophagus. Br J Surg 1960; 48:193-200.
23- Le Quesne LP, Ranger D. Pharyngolaryngectomy with immediate pharyngogastric anastomosis Br J Surg 1966;
53:101-19.
24- Moorehead RJ, Wong J. Gangrene in oesophagal substitutes after resection and bypass procedures for carcinoma of
the oesophagus. Hepatogastroenterol 1990; 37:364-7.
25- Cahow CE, Sasaki CT. Gastric pull-up reconstruction for pharyngo-laryngo-oesophagectomy. Arch Surg 1994;
129:425-30.
26- Sasaki CT, Salzer SJ, Cahow E, Son Y, Ward B. Laryngopharyngoesophagectomy for advanced hypophyseal and
oesophageal squamous cell carcinoma. Laryngoscope1995; 105:160-3.
27- Harrison DFN, Thompson AE. Pharyngolaryngooesophagectomy with pharyngogastric anastomosis for carcinoma
of the hypopharynx. Review of 101 operations. Head Neck Surg 1986; 8:418-28.
28- Goldberg M, Freeman J. transhiatal oesophagectomy with gastric transposition for pharyngolaryngeal malignant
disease. J Thoracic Cardivas Surg 1989; 97:327-33.
29- Matsuburu T, Ueda M, Nakajima T. Elongated stomach roll with vascular microanastomosis for reconstruction of
the esophagus after pharyngolaryngoesophagectomy. J Am Coll Surg 1995; 180:613-5.