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Creden et al. Mini-invasive Surg 2024;8:21 https://dx.doi.org/10.20517/2574-1225.2024.19 Page 3 of 8

These discordant findings must be interpreted in historical context, as the method of gastric conduit
construction confounds some of the findings in the literature. Early esophagectomy series often used the
whole stomach for esophageal replacement, which has inherently worse emptying than a tubularized
conduit [7,13] . A whole intrathoracic stomach is more distensible than a tubularized conduit, and is, therefore,
more prone to dysfunction in part by virtue of the law of LaPlace: the pressure within the stomach (which
resides within the negatively pressurized thoracic cavity after esophageal reconstruction) may not surpass
the pressure of the pylorus [4,14,15] . Furthermore, though the preservation of the lesser curvature preserves
some degree of gastric motility, it also sometimes permits gastroptosis, in which the pylorus lies more
cephalad than the lowest point of the conduit . A retrospective study conducted by Shu et al. in 2013
[16]
found that intrathoracic stomach syndrome occurred with whole stomach reconstruction approximately
[17]
10% of the time, compared to an incidence of 3.3% with tubularized conduit reconstruction . A
prospective study by Zhang et al. in 2011 found similar rates (6%) of delayed gastric emptying yet a
significantly higher rate of reflux esophagitis (21%) among patients who underwent whole stomach, as
compared with gastric tube reconstruction (6%) . The Akkerman meta-analysis also established the
[18]
[7]
tubularized stomach as superior with respect to gastric emptying . Of note, the studies analyzed within the
Urschel meta-analysis - each conducted in the 1990s - largely comprised patients who underwent whole
stomach reconstruction, but this practice is now much less commonplace.

In parallel, the surgical approach for esophagectomy has evolved towards minimally invasive and robotic-
assisted minimally invasive techniques. In 1992, Dallemagne et al. described one of the first cases of a three-
field esophagectomy performed with the assistance of laparoscopy and thoracoscopy, and DePaula et al.
described one of the first cases of a transhiatal esophagectomy in 1995, each of which incorporated a
conventional hand-sewn cervical esophagogastrostomy [19,20] . Watson et al. followed in 1998, describing one
of the first cases of a conventional minimally invasive Ivor Lewis esophagectomy (ILE) using laparoscopy
[21]
and thoracoscopy, in which the esophagogastrostomy was hand-sewn intrathoracically . Soon after,
Horgan et al. described their experience with one of the first robotic-assisted minimally invasive
esophagectomies in 2003 via a transhiatal approach, extolling such benefits as the three-dimensional field of
view, additional degrees of motion, and longer reach of the robotic instruments compared to that of
conventional laparoscopy . Early reports of robotic-assisted minimally invasive ILE soon followed. Of
[22]
note, each of these case reports states that pyloric drainage was not routinely performed, and a tubularized
gastric conduit was employed for reconstruction.

Trends in pyloric drainage have similarly evolved over time, and thus, the effect of pyloric drainage on
outcomes - particularly gastric conduit dysfunction - is inextricably confounded by several technical aspects
of esophagectomy, including the approach. For example, the choice of anastomotic level (cervical vs.
intrathoracic) and route of reconstruction (posterior mediastinal vs. retrosternal) each concomitantly alter
the configuration of the gastric conduit in three-dimensional space. Additionally, no level 1 evidence exists
to support any given approach (transhiatal vs. transthoracic, hybrid vs. minimally invasive, etc.) over
another. Though these variables may be considered when deciding whether to perform a gastric emptying
procedure, the literature does not provide conclusive evidence that either level of the anastomosis or route
of reconstruction independently affects gastric conduit function . Consequently, we also seek high-quality
[7]
evidence on the management of the pylorus during and after robotic-assisted minimally invasive
esophagectomy.