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Ann Thorac Surg 2009;87:1708-1714. doi:10.1016/j.athoracsur.2009.01.075
© 2009 The Society of Thoracic Surgeons
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Jeremiah T. Martin
John A. Federico
Alicia A. McKelvey
Michael S. Kent
Thomas Fabian
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Original Articles: General Thoracic

Prevention of Delayed Gastric Emptying After Esophagectomy: A Single Center's Experience With Botulinum Toxin

Jeremiah T. Martin, MD, John A. Federico, MD, Alicia A. McKelvey, MD, Michael S. Kent, MD, Thomas Fabian, MD*

Section of Thoracic Surgery, Department of Surgery, Hospital of St. Raphael, New Haven, Connecticut

Accepted for publication January 26, 2009.

* Address correspondence to Dr Fabian, 330 Orchard St, Suite 300, New Haven, CT 06516 (Email: tfabian1{at}srhs.org).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

Background: Impaired gastric emptying after esophagectomy contributes to significant morbidity and delayed recovery. Traditional measures to prevent this include pyloromyotomy and pyloroplasty. These procedures are associated with known complications and do not always prevent delayed gastric emptying. Intrapyloric botulinum toxin injection may be an alternative approach to avoiding pyloric obstruction after esophagectomy.

Methods: Patient data were collected in a prospective fashion at a single institution. Forty-eight patients underwent intrapyloric botulinum toxin injection during esophagectomy during a 26-month period (October 2005 to January 2008). Three patients were excluded from analysis because of complications, which interfered with postoperative evaluation of emptying. Forty-five patients were evaluated clinically for signs of delayed gastric emptying. Objective assessment included a dysphagia score in 15, barium swallow in 43, and nuclear gastric emptying scans in 15 patients. The data were also reviewed for evidence of aspiration events leading to pulmonary complications.

Results: Forty-three of 45 patients (96%) had no clinical evidence of delayed gastric emptying in the immediate postoperative period. Four barium studies were interpreted as delayed gastric emptying; however, only 2 patients were symptomatic. These 2 patients underwent balloon pyloric dilation, which resulted in resolution of symptoms in 1. Three additional patients exhibited "late" delayed gastric emptying after initially doing well (mean of 3 months postoperatively) and required endoscopic intervention. No complications were identified in the study related to botulinum toxin injection.

Conclusions: Intrapyloric injection with botulinum toxin is a simple, safe, and effective means of avoiding delayed gastric emptying after esophagectomy. When necessary, reintervention may be performed endoscopically.






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Copyright © 2009 by The Society of Thoracic Surgeons.