Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 01748, USA.
Ann Thorac Surg. 2011 Apr;91(4):1019-24. doi: 10.1016/j.athoracsur.2010.12.055. Epub 2011 Feb 2.
This study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit.
A total of 436 patients underwent esophagectomy with gastric conduit from 2002 to 2009. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter, anastomotic location, and mediastinal route were variable. Gastric outlet obstruction (GOO) was strictly defined to include patients with clinical and radiographic delayed gastric emptying requiring intervention.
Gastric outlet obstruction was found in 22% (98 of 436) of patients who underwent esophagectomy. Pyloromytomy was performed on 52% (51 of 98) of these patients and employed in 41% (179 of 436) of patients in the entire cohort. GOO was present in 28% (51 of 179) of patients who underwent a pyloric drainage procedure compared with 18% (47 of 257) of patients with no pyloric intervention (p = 0.01). Endoscopic balloon dilatation of the pylorus was used to treat 39% (38 of 98) of patients with delayed gastric emptying yielding a 95% (36 of 98) success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators (range,10 to 20 mm). The remaining patients were treated conservatively with prokinetics, nasogastric drainage, or observation. Nasogastric drainage was employed for 7.4 ± 4.4 days in patients with GOO and 6.8 ± 4.0 days in asymptomatic patients (p = 0.15). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. There was a significant difference in postoperative pneumonia (18.4% vs 10.6%, p = 0.05) and median length of hospital stay (12 ± 16 vs 10 ± 9 days, p < 0.0001) in patients with GOO versus normal emptying.
Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.
本研究旨在评估术后幽门球囊扩张术在胃代食管后胃排空延迟中的应用。
2002 年至 2009 年，共有 436 例患者接受了胃代食管手术。所有的食管切除术方法均包括在内，除了采用替代重建或紧急食管切除术的患者。胃管直径、吻合位置和纵隔途径均不同。胃出口梗阻（GOO）的定义严格为包括需要干预的临床和影像学延迟胃排空的患者。
436 例患者中有 22%（98 例）发生胃出口梗阻。对其中 52%（51 例）患者进行了幽门切开术，在整个队列中，41%（179 例）患者采用了幽门引流术。与未行幽门干预的患者（47/257，18%）相比，行幽门引流术的患者中 GOO 发生率为 28%（51/179）（p = 0.01）。对 39%（38 例）胃排空延迟的患者采用内镜下球囊扩张幽门治疗，成功率为 95%（36/98）。采用可控径向扩张食管球囊扩张器（直径 10-20mm）进行幽门扩张。其余患者采用促动力药、鼻胃管引流或观察治疗。GOO 患者的鼻胃管引流时间为 7.4±4.4 天，无症状患者为 6.8±4.0 天（p=0.15）。新辅助放化疗并未增加 GOO 的发生率。GOO 患者术后肺炎发生率（18.4% vs 10.6%，p=0.05）和中位住院时间（12±16 天 vs 10±9 天，p<0.0001）均显著高于排空正常的患者。
尽管行手术引流，但胃代食管后胃排空延迟仍可通过球囊扩张幽门得到有效治疗。
