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Is Intra-operative Botox Injection the Optimal Management of the Pylorus during esophagogastrectomy?
R. J. Cerfolio*, A. S. Bryant, R. Dharwan, C. Canon. University of Alabama at Birmingham, Birmingham, AL,
BACKGROUND: The optimal management of the pylorus during esophagogastrectomy is unknown. Pyloromyotomy and pyloroplasty help reduce the risk of early aspiration but risk life-long biliary reflux, however leaving the pylorus alone may increase the risk of early aspiration.
METHODS: A prospective cohort study of patients who underwent Ivor Lewis esophagogastrectomy by one surgeon. All patients had their stomachs tubularized in the same fashion, had a hand-sewn anastomosis above the azygous vein, had an NGT for three days and the exact same motility agents and duration. Gastric emptying, aspiration events and symptoms were compared.
RESULTS: There were 177 patients who underwent Ivor Lewis between 1/1997 and 6/2007. Outcomes are shown below. Patients who had no pyloric procedure had the most pronounced emptying delay (69%) and highest morbidity (11%) as compared to any other group. Patients who received intra-operative Botox pyloric injection had the lowest rate of significant emptying delay and the lowest morbidity and biliary reflux rates.
CONCLUSIONS: In this a consecutive series of non-randomized patients who received otherwise similar intra-and post-operative care, Botox injection of the pylorus at the time of esophagectomy reduces operative time, seems to improve gastric emptying, decreases the risk of aspiration, reduces morbidity, reduces respiratory complications and decreases hospital length of stay. In addition, it also seems to decrease the risk of long term biliary reflux post-operatively. A prospective randomized trial is needed.
Outcomes by procedure type| Pyloric Procedure | N | Slight Delay in Emptying | Significant Delay in Emptying | Hospital LOS (days) | Morbidity | Biliary Reflux | | Botox | 24 | 16 (67%) | 8 (33%) | 7.3 | 4 (30%) | 0 | | Nothing | 54 | 17 (31%) | 37 (69%) | 8.2 | 32 (59%) | 6 (11%) | | Pyloromyotomy | 71 | 28 (38%) | 43 (62%) | 9.5 | 32 (52%) | 9 (15%) | | Pyloroplasty | 28 | 14 (50%) | 14 (46%) | 8.7 | 16 (57%) | 10 (38%) |
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