Is botulinum toxin injection of the pylorus during Ivor-Lewis esophagogastrectomy the optimal drainage strategy?
Is botulinum toxin injection of the pylorus during Ivor-Lewis esophagogastrectomy the optimal drainage strategy?
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DOI：
10.1016/j.jtcvs.2008.08.049
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发表时间：
2009-03-01
影响因子：
6
通讯作者：
Eloubeidi, Mohamad A.
中科院分区：
文献类型：
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作者：
Cerfolio, Robert James;Bryant, Ayesha S.;Eloubeidi, Mohamad A.
背景：食管胃切除术期间幽门的最佳处理尚不清楚。幽门肌切开术和幽门成形术会导致早期水肿，并有长期胆汁反流的风险；然而，缺乏幽门引流可能会带来早期误吸的风险。方法：我们利用前瞻性数据库对接受 Ivor-Lewis 食管胃切除术的食管癌或高度不典型增生患者进行了一项回顾性研究。所有患者都有一名外科医生和相似的胃管化、手工缝合吻合术、鼻胃管持续时间和术后促动力剂。比较术后胃排空、误吸和吞咽症状的结果。结果：1997年1月至2008年6月期间，共有221名患者。 71 名患者接受了幽门肌切开术，术后第 4 天判断胃排空延迟的患者有 93%（52% 有任何发病情况，14% 有呼吸道疾病）。 54 名患者没有进行引流手术，96% 的患者胃排空延迟（59% 有任何发病率，22% 有呼吸道疾病）。 28 名患者接受了幽门成形术，其中 96% 出现胃排空延迟（50% 有任何发病情况，32% 有呼吸道疾病）。六十八名患者接受了幽门肉毒杆菌毒素注射。仅 59% 的患者出现胃排空延迟（P = 0.002，44% 的患者有任何发病情况，13% 的患者有呼吸道疾病）。肉毒杆菌毒素组的住院时间 (P = .015) 和手术时间 (P = .037) 较短。随访（平均 40 个月）显示，肉毒杆菌毒素组的胆汁反流症状最低（P = .024）。结论：与幽门成形术或幽门肌切开术相比，在食管胃切除术时向幽门注射肉毒杆菌毒素是安全的，并且可以缩短手术时间。此外，它还可以改善早期胃排空，减少呼吸道并发症，缩短住院时间，并减少晚期胆汁反流。需要进行前瞻性多机构随机试验。
Background: The optimal management of the pylorus during esophagogastrectomy is unknown. Pyloromyotomy and pyloroplasty cause early edema and risk long-term bile reflux; however, the lack of pyloric drainage might risk early aspiration.Methods: We performed a retrospective study with a prospective database on patients with esophageal cancer or high-grade dysplasia who underwent Ivor-Lewis esophagogastrectomy. All had one surgeon and similar stomach tubularization, hand-sewn anastomoses, nasogastric tube duration, and postoperative prokinetic agents. Outcomes of postoperative gastric emptying, aspiration, and swallowing symptoms were compared.Results: Between January 1997 and June 2008, there were 221 patients. Seventy-one patients had a pyloromyotomy, and gastric emptying judged on postoperative day 4 was delayed in 93%(52% had any morbidity and 14% had respiratory morbidity). Fifty-four patients had no drainage procedure, and gastric emptying was delayed in 96% (59% had any morbidity and 22% had respiratory morbidity). Twenty-eight patients underwent pyloroplasty, and 96% had delayed gastric emptying (50% had any morbidity and 32% had respiratory morbidity). Sixty-eight patients had botulinum toxin injection into the pylorus. Gastric emptying was delayed in only 59% (P = .002, 44% had any morbidity and 13% had respiratory morbidity). Hospital length of stay (P = .015) and operative times (P = .037) were shorter in the botulinum toxin group. Follow-up (mean, 40 months) showed symptoms of biliary reflux to be lowest in the botulinum toxin group (P = .024).Conclusion: Injection of the pylorus with botulinum toxin at the time of esophagogastrectomy is safe and decreases operative time when compared with pyloroplasty or pyloromyotomy. In addition, it can improve early gastric emptying, decrease respiratory complications, shorten hospital stay, and reduce late bile reflux. A prospective multi-institutional randomized trial is needed.