Arya S, Markar S R, Karthikesalingam A, Hanna G B
Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK.
Dis Esophagus. 2015 May-Jun;28(4):326-35. doi: 10.1111/dote.12191. Epub 2014 Feb 24.
Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty-five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non-significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.
食管切除术后胃管道排空延迟可能与包括吸入性肺炎和吻合口漏在内的并发症发生率增加有关。本系统评价的目的是评估食管切除术后幽门引流的当前方式及其对吻合口完整性和术后发病率的影响。检索了Medline、科学网、Cochrane图书馆、试验注册库和会议论文集。评估了食管切除术后的五种幽门管理策略：不干预、肉毒杆菌毒素（肉毒素）注射、手指骨折、幽门成形术和幽门肌切开术。评估的结果包括医院死亡率、吻合口漏、肺部并发症、胃排空延迟以及胆汁反流的晚期并发症。分析了包含3172例患者的25篇出版物。对2000年后发表的六项比较研究的汇总分析显示，幽门引流与吻合口漏、肺部并发症和胃排空延迟发生率降低的非显著趋势相关。总体而言，关于个体幽门引流策略优点的当前证据水平仍然很低。临床结果的定义存在显著异质性，尤其是胃排空延迟，这阻碍了对食管切除术中幽门管理进行有意义的评估并形成共识。食管切除术后采用幽门引流程序时，吻合口漏、肺部并发症减少以及胃淤滞减轻的趋势不显著。然而，理想的技术仍未得到证实，这表明需要进一步的合作研究来确定能最大限度发挥幽门干预潜在益处（若有）的干预措施。
