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Page 6 of 8 Creden et al. Mini-invasive Surg 2024;8:21 https://dx.doi.org/10.20517/2574-1225.2024.19

[27]
as demonstrated by Saeed et al. in their retrospective review . The two most recently published meta-
analyses grouped all patients who undergo a pyloric drainage procedure, whether permanent
(pyloromyotomy and pyloroplasty) or temporary (dilatation and chemodenervation) [6,7,9,10] . Moreover,
gastric conduit dysfunction - including the closely related clinical entities of gastric outlet obstruction,
delayed gastric emptying, acquired pyloric stenosis, and intrathoracic stomach syndrome - is variably
defined in the body of literature (whether by subjective symptom profile, a radiologist’s impression of a
barium esophagram, or quantitative gastric scintigraphy), complicating objective comparison and meta-
analysis [8,11,14,33] .

The transience of the newer alternatives to surgical pyloric drainage is worth further consideration. Most
episodes of gastric conduit dysfunction occur within the first 30 days of the index operation when
[11]
postoperative edema may be a significant contributing factor . The effects of chemodenervation and
dilatation are temporary, whereas surgical pyloromyotomy or pyloroplasty and endoscopic pyloromyotomy
(i.e., G-POEM or POP) permanently alter the patient’s anatomy. Lanuti et al. employed selective endoscopic
balloon dilatation ad hoc when there was symptomatic, endoscopic, or radiographic evidence of gastric
[4]
conduit dysfunction, touting an impressive 95% success rate in resolution . Repeat intervention was not
described within the same cohort, and only five patients within the cohort of 98 patients developed gastric
conduit dysfunction beyond one year after their index operation. Taken together, these data suggest that
endoscopic balloon dilatation or chemodenervation could adequately address early (i.e., within 30 days)
gastric conduit dysfunction with minimal risk of late gastric conduit dysfunction. With translational studies
drawing increased attention to the regenerative potential of the gastric myenteric plexus (and hence
gastropyloric motility) after esophagectomy [33,34] , a selective temporary pyloric drainage procedure, rather
than a permanent pyloroplasty or pyloromyotomy, is an appealing strategy for those with early signs of
gastric conduit dysfunction. In addition, G-POEM is emerging and is our preferred selective approach to
pyloric drainage for the minority of patients with durable signs of delayed gastric emptying after
esophagectomy. We have adopted this approach to manage the pylorus in a selective fashion with G-POEM
and have anecdotally noted a very low risk of functional side effects as compared with surgical pyloroplasty.
Though studies have established the safety and efficacy of G-POEM, comparative studies have not yet been
TM
conducted [1,28-31] . Impedance planimetry [EndoFLIP (endoluminal functional lumen imaging probe),
Medtronic, Minneapolis, MN] utilizes an endoscopically placed catheter equipped with a cylindrical balloon
that can be inflated to various diameters to allow dynamic assessment of sphincter distensibility. While its
use in assessing esophageal motility and lower esophageal sphincter distensibility is becoming increasingly
commonplace, its use to assess abnormal pyloric distensibility is under investigation. In the future, it may
help individualize management of the pylorus after esophagectomy.

CONCLUSION
Though more than a century has passed since the first esophagectomy, controversy remains regarding many
technical details, including management of the pylorus. In particular, the debates regarding the optimal
technique to manage the pylorus and whether a pyloric intervention should be performed dogmatically at
the time of esophagectomy or selectively for symptomatic post-esophagectomy patients have yet to be
resolved. While addressing these debates, a standardized definition and classification of gastric conduit
dysfunction after esophagectomy is critical to allow proper analyses in future comparative effectiveness
studies. The contemporary era of robotic-assisted surgery has facilitated the performance of pyloric
drainage via pyloroplasty and pyloromyotomy, and advanced third-space endoscopy now provides the
option of selective pyloric drainage via a G-POEM. Given the rising incidence of esophageal cancer and the
growing adoption of robotic-assisted minimally invasive esophagectomy, high-quality prospective studies
are needed to settle one of the most enduring debates in thoracic surgery. Until then, we suggest a selective
approach to pyloric drainage.