Asian Cardiovasc Thorac Ann 2004;12:19-22
© 2004 Asia Publishing EXchange Ltd
Application of Mechanical Dilatation of the Pyloric Sphincter in Esophagectomy for Esophageal Carcinoma
Yong-Qing Wang, MD,
Wei-Wen Ye, MD,
Tao Lu, MD,
Wei-Ming Zhang, MD,
Yong Xu, MD
Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, College of Medical Science, Zhejiang University, Hangzhou, People’s Republic of China
For reprint information contact: Yong-Qing Wang, MD Tel: 86 571 8609 0073 Fax: 86 571 8604 4817 Email: dr_ygwang{at}sina.com Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, College of Medical Science, Zhejiang University, Hangzhou 310016, People’s Republic of China.
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ABSTRACT
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The objective of this study was to investigate the effectiveness of additional intraoperative mechanical dilatation of the pyloric sphincter in order to prevent early postoperative gastric retention after esophagectomy using the stomach as substitute for esophageal carcinoma patients. Between October 2001 and May 2002, 32 consecutive esophageal carcinoma patients were treated with esophagectomy combined with additional intraoperative mechanical dilatation of pyloric sphincter (trial group). Another 30 patients underwent esophagectomy without additional intraoperative mechanical dilatation of the pyloric sphincter (control group). Both groups were compared in the following aspects: amount of postoperative GI drainage, time of flatus, intrathoracic gastric fluid retention and other surgical related complications. The amount of GI drainage in the trial group was significantly less than that in the control group ( p < 0.05), and time of anal exsufflation was 1 to 2 days. X-ray demonstrated only 0 to 25% of intrathoracic gastric fluid retention and no related complications such as anastomotic leakage, so the patients in the trial group suffered less gastric reflux. Additional intraoperative mechanical dilatation of the pyloric sphincter in radical esophagectomy can accelerate gastric emptying, the recovery of gastric-intestinal function and obviously decrease the occurrence of early postoperative gastric retention and related complications. This method does have the advantages of ease of performance, confirmed effectiveness and safety. It can be utilized in radical esophagectomy through any approach of thoracotomy.
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INTRODUCTION
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Early postoperative gastric retention after radical esophagectomy is not rare,1–3 especially in patients with the stomach in the right thoracic cavity. Our research investigated the effectiveness of additional intraoperative dilatation of the pyloric sphincter with a mitral commissurotomy dilator to prevent early postoperative gastric retention after radical esophagectomy.
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PATIENTS AND METHODS
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32 patients who underwent radical esophagectomy combined with additional intraoperative dilatation of the pyloric sphincter with a mitral commissurotomy dilator between October 2001 and May 2002 were included in the trial group. Another 30 patients who underwent radical esophagectomy without additional intraoperative dilatation of the pyloric sphincter between January 2001 and September 2001 were included in control group. No patients in either of the groups received preoperative chemotherapy. The indications of esophagectomy were similar in both groups. There were 25 male and 7 females with an age range of 45 to 77 years (56.47 ± 8.50) in the trial group. Intrathoracic gastroesophagostomy was performed through left thoracotomy in 26 patients and left cervical gastroesophagostomy combined with right thoracotomy was performed in 6 patients in this group. There were 27 male and 3 females with an age range of 50 to 70 years (63.82 ± 5.76) in the control group. Intrathoracic gastroesophagostomy was performed through left thoracotomy in 25 patients and left cervical gastroesophagostomy combined with right thoracotomy was performed in 5 patients in this group. None of the patients had a history of ulcer or scarring near the pylorus in either group.
With regard to the operational techniques followed for the trial group, 26 cases were performed through a left thoracotomy and only 6 cases through a right thoracotomy combined with a laparotomy and neck incision because the lesion was high at upper segment of the thoracic esophagus. The radical esophagectomy was performed using the stomach as a substitute and the stomach was dissected to pylorus in the usual fashion. A mitral commissurotomy dilator was adjusted to a width of 3.0 to 3.5 cm. It could be passed through the residual orifice of the stomach or the gastrotomy opening, in which the end to end anastomosis (EEA) instrument would be put to perform the stapled anastomosis. It was easily guided through the pylorus into the duodenum with the operator’s hand. The ideal position of the dilator was with one half to one third of the tip passing through the pyloric canal. The dilatation was performed two to three times prior to withdrawal (Figure 1
). The effectiveness of the procedure was checked with the index finger passing through the pyloric canal to assure adequate dilatation (Figure 2). Esophagogastrostomy was finished by manual sewing or anastomat. The GI tube was then passed through the anastomosis directly into the stomach. The tube was kept in position for 3 to 5 days after surgery until exsufflation, then a fluid-diet was ordered for 2 to 5 days, and a semi-liquid diet ordered sequentially.
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Figure 2. The effectiveness of the procedure was checked with the index finger passing through the pyloric canal easily to assure adequate dilatation.
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For the control group, 25 cases were performed through a left thoracotomy only and 5 cases through a right thoracotomy combined with a laparotomy and neck incision. The radical esophagectomy was performed using the stomach as a substitute and the stomach was mobilized to pylorus. Esophagogastrostomy was performed by manual suturing or anastomat without additional intraoperative dilatation of pyloric sphincter. The postoperative management was the same as that for the trial group.
The postoperative observation indices included:
- Amount of drainage from gastrointestinal tube;
- Time of recovery of flatus;
- Degree of intrathoracic gastric fluid retention by chest X-ray study;
- Related complications.
For statistical analysis, all values are expressed by mean ± standard deviation processed by t-test and p < 0.05 was considered as statistically significant. All statistical process was completed with Statistics Package for Social Science (SPSS Version 8.0).
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RESULTS
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All the patients were kept nothing per oral (NPO) in the first three days and total parenteral nutrition was given. 24 hours’ amount of GI drainage (with subtraction of fluid by irrigation) was recorded in both groups (Table 1). The amount of the GI drainage after surgery was significantly less ( p < 0.05) in the trial group than that in the control group. The results indicate that the additional intraoperative mechanical dilatation of the pyloric sphincter played an effective role in acceleration of early stomach emptying and caused a decrease in postoperative gastric retention. In addition, the time of flatus was earlier in the trial group than that in the control group ( p < 0.05). Table 2 shows that the additional intraoperative mechanical dilatation of pyloric sphincter can accelerate recovery of gastric-intestinal function.
In order to investigate and compare the severity of postoperative gastric fluid or diet-residues’ retention in these two groups, chest X-rays of both posterior-anterior and lateral positions were ordered on the 7th day after surgery. The degree of intrathoracic gastric retention was assessed with gastric fluid or diet volume percentage in the whole intrathoracic stomach, which was estimated by chest X-ray. The average degree of intrathoracic gastric retention in 28 patients who underwent X-ray in the trial group was 13.53% ± 8.25%, while it was 40.59% ± 10.29% in 21 patients who underwent X-ray in the control group. The degree of postoperative intrathoracic gastric retention in the trial group was much lower than that of the control group (Figure 3).
The accumulation of intrathoracic gastric fluid may cause vomiting, chest discomfort, shortness of breath and other detriments to a patient’s quality of life. Cardiac and pulmonary function may be impaired by compression of inflated intrathoracic stomach. Meanwhile gastric wall necrosis and anastomotic leakage is likely due to blood supply impairment. There were no gastric retention related complications in the trial group (32 patients) and the patients resumed an oral diet 2 to 5 days earlier than the control group. On the contrary, in the control group, four patients underwent postoperative pylorodiosis under gastroscope two weeks after surgery because of severe intrathoracic retention and one patient had anastomotic leakage. More patients suffered from gastric reflux in control group.
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DISCUSSION
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Postoperative intrathoracic gastric retention after radical esophagectomy for esophageal carcinoma patients is not rare. It may occur due to the following reasons:
- Resection of the vagus nerve of the stomach leads to impairment of gastric evacuation by gastric dysperistalsis because of gastric dysrhythmia;
- Negative pressure in the thoracic cavity and anatomical destruction of esophageal hiatus decrease the gastric tonicity and impair the gastric evacuation;
- Decreased gastric tonicity due to inflated stomach and sharp angle formation of the residual stomach at the diaphragmatic level impede the gastric evacuation;
- Temporary pylorospasm is likely to happen because of excessively increased intrathoracic stomach volume due to malfunction of GI drainage, excessive diet or retraction of lesser curvature of the stomach.
All of the above would cause impairment of gastric evacuation and retention. At present, there is no ideal method to prevent the early-stage postoperative gastric retention after radical esophagectomy for esophageal carcinoma. Some authors conducted research on postoperative intrathoracic gastric function after esophagectomy for esophageal carcinoma with isotope technique. The results showed that the residual stomach evacuates much quicker in patients who underwent simultaneous intraoperative pyloromyotomy or pyloroplasty than in patients without intraoperative pyloromyotomy or pyloroplasty. It may improve patients’ postoperative quality of life and prevent or decrease the occurrence of early-stage postoperative gastric retention.4 This idea is supported by many authors.5,6
Our research confirms that intraoperative additional use of a mitral commissurotomy dilator to dilate the pyloric sphincter can improve the postoperative intrathoracic gastric evacuation and recovery of gastric-intestinal function, and markedly decrease the occurrence of postoperative intrathoracic gastric retention related complications. Traditional Heinecke-Mikulicz (HM) pyloromyotomy, finger-pressed pyloroplasty and intraoperative dilatation of the pyloric sphincter by balloon have been widely performed up to now. Traditional HM pyloromyotomy has been gradually abandoned due to its destruction of the pyloric sphincter and permanent loss of pyloric function. Furthermore, its use was also restricted because of the relatively poor exposure of pylorus, especially through the left thoracotomy, making it less easy to handle. Animal experiments and clinical application certified that the relaxation status of the dilated pylorus was temporary and the injured muscular fiber would recover gradually with the resumption of the gastric peristaltic function in the other two methods. The normal function of the pylorus was recovered in eight weeks after surgery and maintained well.7,8 Further observation is needed for finger-pressed pyloroplasty and intraoperative dilatation of pyloric sphincter by balloon because of the uncertainty of dilatation strength and degree.
The use of a mitral commissurotomy dilator as in these cases is very similar to balloon dilatation or finger pressed pyloroplasty. But the usage of the mitral commissurotomy dilator has the advantages of ease of handling, confirmed effectiveness, safety for radical esophagectomy in any approach and the avoidance of destruction of pyloric function. It is considered worthy of wide clinical use.
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REFERENCES
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- Zhao Xi-jiang, Zhang Xi-zeng et al. Esophagoplasty. Tianjing scientific translation publication company
1994;139–50.
- Zhao Chong-wei, Li Xi-bo, Jia Shi-quan et al. Clinical application and measurement of intra-thoracic gastric function after esophagectomy. Chinese Journal of Surgery
1993;31:115–7.
- Wang Qi-bin, Lu Bi-hong, Zhu Wei-dong. 30 cases of clinical experience on intra-thoracic gastric emptying after radical esophagectomy. Jiangsu Clinical Medicinal Journal
2001;5:121–2.
- Wang Yong-gang, Zhang Ru-gang, Zhang Da-wei. Research on intra-thoracic gastric function after esophagectomy. Chinese Journal of Tumor
1997;19:385–8.
- Zhao Chong-wei, Wang De-jiang, Pan Shu-hua et al. Total gastric replacement of esophagus through primary esophageal-bed in the treatment of high positioned esophageal carcinoma. Journal of Shandong Medical University
1991;29:149–51.
- Tu Gui-yi. The head and neck surgeon’s role in the management of cervical esophageal cancer. Protocol of the 10th Asia Pacific Cancer Conference
1991;213.
- Li Qing-bo, Sun Xiu-ji, Ren Hong-ling et al. Clinical observation of finger-pressed pyloroplasty in prevention of postoperative reflux esophagitis after esophagectomy for esophageal carcinoma or esophago-gastrectomy for cardiac-end gastric carcinoma. Practical Cancer Journal
1998;13:254.
- He Mao-yuan, Guo Hong-shan, Liu Hai-tao et al. Research on prevention of early-stage gastric retention by use of intraoperative balloon dilatation of pylorus for esophagectomy. Shandong Medicine
2000;40:13–4.
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ABSTRACT
INTRODUCTION
