Endoscopic pyloric balloon dilatation obviates the need for pyloroplasty at esophagectomy

Because the rate of acquired pyloric stenosis (APS) from truncal vagotomy is 15%, many surgeons perform pyloroplasty or pyloromyotomy at the time of esophagectomy. Endoscopic pyloric balloon dilatation (EPBD) is another method to manage APS. This study evaluated a cohort treated with preoperative EPBD.

This is a retrospective review of all patients treated with preoperative EPBD and esophagectomy for cancer from 2002 to 2009 at Brigham and Women's Hospital, a tertiary care center. Outcome measures included need for subsequent surgery for gastric outlet obstruction, rate of pyloric stenosis noted on postoperative endoscopy, and complications.

Upon review of the series, 25 patients (80% male; median age, 63 [range 47-81] years) had outpatient preoperative EPBD and esophagectomies 1-2 weeks later and were included in the study. None had pyloroplasties or pyloromyotomies at the time of esophagectomy. Selected patients had postoperative endoscopy. Of the 25 patients, 20 had transhiatal esophagectomies, 3 had thoracoabdominal esophagectomies, and 2 had VATS 3-hole esophagectomies. Median follow-up time was 22 (range, 1-84) months. There were no complications from EPBD. There were no postoperative deaths. No patient needed a second operation for gastric outlet obstruction. All patients had postoperative barium swallows (BaS) or endoscopy or both. Only one patient (4%) required one postoperative EPBD to dilate a 16-mm pylorus. Three others had delayed gastric emptying on BaS with endoscopy showing each pylorus was wide open. Their symptoms improved with time.

In this cohort, preoperative EPBD in all patients combined with postoperative EPBD in one patient obviated the need for pyloroplasty. This approach merits further study in a larger cohort, particularly to determine whether preoperative EPBD is necessary or if only selected postoperative EPBD is sufficient.