Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Ann Thorac Surg. 2014 Jun;97(6):1959-64; discussion 1964-5. doi: 10.1016/j.athoracsur.2013.11.026. Epub 2014 May 1.
Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy.
We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both.
Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping.
Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy.
幽门内肉毒杆菌毒素注射已成为标准幽门引流术的一种替代方法。可能的优点包括手术时间缩短，术后倾倒和胆汁反流症状减少。然而，缺乏数据表明其与标准引流术相比的有效性。本综述的目的是比较一组接受幽门内肉毒杆菌注射的患者与接受幽门肌切开术或幽门成形术加食管切除术的患者的结果。
我们对 2005 年至 2010 年在一家机构接受开放性食管切除术的所有患者的前瞻性数据库进行了回顾性分析。322 例患者分为 3 组进行分析：肉毒杆菌注射组（n=78）、幽门肌切开术组（n=45）和幽门成形术组（n=199）。我们比较了这些组的手术时间、术后吞咽研究中胃排空延迟的存在、吻合口扩张的需要、幽门扩张的需要、术后促动力药物的使用以及患者术后反流或倾倒症状的发生情况或两者兼而有之。
接受肉毒杆菌注射的患者在术后影像学评估中出现类似的胃排空延迟，与接受幽门肌切开术和幽门成形术的患者相同（分别为 16%、5%和 13%；p=0.14）。接受肉毒杆菌注射的患者的平均手术时间明显缩短，预计为 239 分钟，而接受幽门肌切开术和幽门成形术的患者分别为 312 分钟和 373 分钟（p<0.001）。然而，更多接受肉毒杆菌和幽门扩张的患者（分别为 22%、4%和 2%；p<0.001）出现术后反流症状（分别为 32%、12%和 13%；p=0.001）和使用术后促动力药物（分别为 22%、5%和 15%；p=0.04）。在术后倾倒方面，各组之间没有统计学差异。
使用幽门内肉毒杆菌注射显著缩短了手术时间。然而，接受肉毒杆菌注射的患者出现更多的术后反流症状，需要更多地使用促动力药物，并需要术后内镜干预，而该可逆手术并不能减少术后倾倒。幽门内肉毒杆菌注射不应作为标准引流术的替代方法。幽门肌切开术似乎是与食管切除术一起选择的引流术。
