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Creden et al. Mini-invasive Surg 2024;8:21 https://dx.doi.org/10.20517/2574-1225.2024.19 Page 5 of 8

potential therapy for delayed gastric emptying following esophagectomy [1,28-31] . As its name suggests, G-
POEM was derived from the technique of peroral endoscopic myotomy (POEM), which is well-described
for the treatment of achalasia. Via an endoscopic approach, a longitudinal or transverse mucosotomy is
made approximately 5 cm proximal to the pylorus (posteriorly and slightly towards the lesser curve) and a
submucosal tunnel is created with electrosurgical dissection. After extending the submucosal tunnel into the
duodenal bulb and completely exposing the pyloric ring, the pylorus is divided longitudinally. The
mucosotomy is closed with either through-the-scope clips or endoscopic suture. It should be noted that
while it is easier to enter the submucosal plane through a transverse mucosotomy, a longitudinal
mucosotomy is easier to close.

A separate but related technique has been described wherein the muscularis of the pylorus and the overlying
[30]
mucosa are incised directly via an endoscopic approach at the time of esophagectomy . Comparative data
are yet lacking for the application of G-POEM specifically to pyloric drainage after esophagectomy, but
Nammour et al. reported a series of 11 patients with delayed gastric emptying after esophagectomy who
experienced favorable results with G-POEM, with patients reporting a lower burden of symptoms and
gastric scintigraphy demonstrating improvement or normalization of gastric emptying in 87.5% of
examined patients after the procedure . Notably, 81.8% of the cohort (9 of 11) had previously undergone
[29]
pyloric chemodenervation and were experiencing recurrent or recalcitrant symptoms.

DOGMATIC VS. SELECTIVE PYLORIC DRAINAGE
The advent of robotic-assisted surgery has undeniably revolutionized the care of patients undergoing
esophagectomy. What was formerly a procedure that mandated large incisions in two or three body cavities
can now be performed in a hybrid or even exclusively minimally invasive fashion. Moreover, endoscopic
techniques for managing postoperative complications including delayed gastric emptying have since been
developed since the introduction of minimally invasive approaches. Dogmatic pyloroplasty and
pyloromyotomy arose in an era when a redo laparotomy, which confers a significant risk of complications
and need for recovery in immunocompromised cancer patients, was the primary option for patients with
delayed gastric emptying after esophagectomy who did not undergo pyloroplasty or pyloromyotomy at the
index operation. Since then, robotic-assisted laparoscopic pyloric drainage in a separate setting and
[2]
endoscopic therapies including pyloric chemodenervation with onabotulinum toxin , endoscopic balloon
dilatation , and G-POEM have emerged as minimally invasive options, which has subsequently enabled a
[14]
[1]
more selective approach to pyloric drainage after esophagectomy.
When comparing dogmatic vs. selective pyloric drainage, several clinical outcomes warrant consideration.
Directly related functional outcomes include gastric outlet obstruction, dumping syndrome, and bile reflux.
Indirectly related clinical outcomes (e.g., those suggestive of or caused by conduit distension) include
postoperative aspiration, anastomotic leak, and acid reflux. With increased attention on quality-of-life
outcomes, the influence of pyloric drainage on postoperative dysphagia, odynophagia, nausea and vomiting,
reflux, regurgitation, cough, and weight loss also warrants consideration . Nevertheless, the presence or
[32]
absence of any of the above signs or symptoms may be confounded by numerous other factors. Particularly
troublesome to parse out are symptomatic reflux and esophagitis, which may be due to either reflux of bile
(to which pyloric drainage may contribute) or the inadequate clearance of swallowed material (to which the
lack of pyloric drainage may contribute); indeed, patient questionnaires have reported both higher and
lower rates of reflux after pyloric drainage .
[15]

Study design further complicates interpretation of the available literature. Among retrospective studies and
meta-analyses, pyloroplasty and pyloromyotomy are often combined, yet they may have different outcomes,