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Page 2 of 8 Creden et al. Mini-invasive Surg 2024;8:21 https://dx.doi.org/10.20517/2574-1225.2024.19

recently) endoscopic pyloromyotomy. Intervention can be performed preoperatively, at the time of
esophagectomy, routinely in the postoperative phase, or selectively in the postoperative phase in response to
specific obstructive complications.

The many and varied techniques and strategies for pyloric drainage have developed and evolved alongside
the approach to the esophagectomy itself - chiefly from conventional open two- or three-field approaches to
hybrid and even completely minimally invasive approaches. The historical context of pyloric drainage is
inseparable from the advent of minimally invasive and robotic-assisted minimally invasive surgery, and
thus, an understanding of the approach to pyloric drainage in the era of robotic-assisted minimally invasive
surgery requires an exploration of the history of all aspects of the esophagectomy.

THE CONTROVERSY: THE EFFECT OF PYLORIC DRAINAGE ON GASTRIC CONDUIT
FUNCTION AFTER ESOPHAGECTOMY
Proponents of pyloric drainage during or immediately after esophagectomy invoke surgical dogma from the
era prior to anti-secretory medications when peptic ulcer disease was common. One common operation for
peptic ulcer disease was a bilateral truncal vagotomy, which necessitated pyloric drainage. Because bilateral
truncal vagotomies are intrinsic to nearly all esophagectomies, the gastric conduit demands the same
consideration. Indeed, pyloric drainage yields decreased rates of delayed gastric emptying when compared
[1-7]
to the absence of an emptying procedure (10% and 50%) . Purported downstream clinical effects include a
[8]
decreased rate of morbidity, particularly aspiration pneumonia and anastomotic leakage . However, the
literature has not consistently supported these theoretical benefits. A retrospective cohort study conducted
by Antonoff et al. found that routine pyloric drainage was associated with a lower need for postoperative
pyloric dilatation during the index hospitalization and a reduced risk of postoperative aspiration . In
[9]
contrast, a meta-analysis by Urschel et al. demonstrated pyloric drainage did not reduce the risk of
[10]
aspiration with statistical significance . In addition, long-term morbidity (including anastomotic leakage)
and mortality were not influenced by pyloric drainage, a finding corroborated by Antonoff et al.’ study [9,10] .

Critics of pyloric drainage highlight that the procedure is not without consequences. It is associated with a
10% to 20% risk of postoperative dumping and a 5% risk of bile reflux, which can be challenging to
manage [2,4,5,9,11] . Though pyloric drainage is designed to facilitate conduit emptying, subsequent postoperative
edema at the level of the pylorus may have a transient paradoxical effect, impairing drainage until the edema
resolves. Indeed, Lanuti et al. found, in a retrospective review, that delayed gastric emptying (defined for
their purposes as the presence of symptoms, radiographic evidence of delayed emptying on barium swallow,
persistently dilated conduit with air-fluid level, or retained food on esophagoscopy) occurred at a higher
rate after pyloric drainage (18.2%) than without (9.6%) . Finally, pyloroplasty and pyloromyotomy are
[11]
associated with a risk of a leak, albeit rare: Antonoff et al. reported major complications directly related to
pyloromyotomy or pyloroplasty in two of their cohort of 293 patients, one of whom died as a result of those
[9]
complications .

Further reservations include the small effect size of pyloric drainage on the rates of gastric conduit
dysfunction. While the Urschel meta-analysis demonstrated a trend favoring pyloric drainage as protective
against delayed gastric emptying, this trend did not reach significance. Fritz et al. omitted pyloric drainage
in 170 consecutive patients undergoing esophagectomy and found similar rates of gastric conduit
dysfunction (16.5%) as those who undergo pyloric drainage . Another meta-analysis by Akkerman et al. in
[12]
[7]
2014 corroborated this result .