Laparoscopic and thoracoscopic esophagectomy offers clear benefits regarding surgical trauma, duration of operation, and postoperative recovery. Tsujimoto et al. reported that, compared to open gastric tube reconstruction, laparoscopy-assisted gastric tube reconstruction significantly reduces the postoperative systemic inflammatory response syndrome, which is often linked with increased postoperative complications [10]. Additionally, several innovative minimally invasive approaches, such as robot-assisted esophagectomy, mediastinoscopic esophagectomy, and flexible gastroscopic esophagectomy, have been developed [11–13]. These methods promise to further decrease surgical trauma and the incidence of postoperative complications. Future research is necessary to verify the effectiveness of these new techniques.
Gastric esophagoplasty for esophagectomy, first introduced by Akiyama in 1972, is now employed by approximately 90% of surgeons in Europe, 80% in Asia, and 79% in North America, owing to its superior advantages. This technique benefits from the anatomical proximity and rich vascularization of the stomach and has demonstrated improved long-term outcomes in terms of quality of life and nutritional status post-esophagectomy [4, 14–16]. Research by Wenxiong Zhang et al. has shown a significant reduction in the incidence of reflux and intrathoracic gastric syndrome in patients undergoing esophageal reconstruction with a gastric tube. The authors attribute these improvements to the gastric tube of the reconstructed esophagus, which minimizes the duration that food remains in the gastric tube. Additionally, the surgical creation of the gastric tube often involves the removal of the portion of the stomach that contains acid-secreting glands, thereby decreasing the gastric acid concentration and further reducing postoperative reflux rates [4].
However, some studies advocate for the advantages of using the whole stomach approach over the gastric tube method for esophagectomy. The whole stomach maintains superior blood supply, primarily due to the submucosal vessels that predominantly nourish the distal part of the stomach and the anastomosis, thereby reducing the risk of esophagogastric anastomosis leakage. Additionally, this approach enhances the stomach's capacity for food storage and improves its ability to absorb and digest nutrients, potentially mitigating the risk of anemia resulting from impaired absorption. These benefits are underscored by angiographic comparisons among three types of esophagoplasty: the narrow gastric tube, the wide gastric tube, and the whole stomach. The findings indicate that both the wide gastric tube and the whole stomach maintain adequate blood supply, whereas the anastomosis site in the narrow gastric tube configuration exhibits significantly poorer vascularity. Consequently, the authors recommend the use of either a whole stomach or a wide-tube configuration to optimize anastomotic healing [3].
In a study involving 37 cases of whole stomach esophagoplasty with preoperative pyloric balloon dilatation, the entire gastric tube was successfully inserted into the neck via the posterior mediastinum. Our findings suggest that this anatomical location offers optimal conditions for the gastric tube within the mediastinal cavity due to its spaciousness and relatively shorter distance compared to alternative placements. Notably, our investigation reported two cases of anastomotic leak (graded as grade 2 according to the Clavien Dindo classification) and four cases of anastomotic stenosis, which manifested late postoperatively, typically occurring 2–3 months after the surgical procedure. JM Collard conducted a comparative study involving two groups of patients undergoing esophagoplasty, one with a gastric tube and the other with a whole stomach. The results revealed that the whole stomach group exhibited a significantly lower incidence of anastomotic stenosis (22.3% vs. 6%, p = 0.008). Additionally, patients in the whole stomach group reported improvements in the number of daily meals, reduced sensations of early fullness, enhanced comfort during eating, and preserved stomach capacity. Furthermore, examination of blood vessels beneath the mucosa was found to be more effectively conducted in the whole stomach group [17].
Postoperative delayed gastric emptying commonly occurs following esophagectomy with gastric bypass surgery, with reported rates ranging from 2.2–47% [18]. In 2020, diagnostic criteria for delayed gastric emptying after esophagectomy were established by Delphi consensus following a conference of leading experts in esophageal surgery from Europe, North America, and Asia, representing regions with advanced surgical expertise in esophageal procedures [9]. In our study, patients were clinically monitored for signs such as gastric tube fluid output and respiratory difficulties. Additionally, on the third day post-surgery, circulation imaging with water-soluble contrast was conducted and evaluated according to the Delphi standards. The primary cause of postoperative delayed gastric emptying is attributed to pyloric dysfunction, characterized by reduced motility of the digestive tract resulting from the excision of the vagal nerves during esophageal surgery. This "dullness" of the pylorus contributes significantly to delayed gastric emptying. Furthermore, other factors, such as impedance to food circulation from the chest to the abdomen due to pressure differentials or twisting of the gastric tube, may also play a role in exacerbating this condition. According to Lei Zhang's study, which evaluated 285 patients undergoing esophagoplasty with either whole stomach or gastric tube without pyloroplasty following esophagectomy for cancer, the overall incidence of delayed gastric emptying was 18.2%. Specifically, the incidence of delayed gastric emptying was higher in the whole stomach gastroplasty group compared to the gastric tube gastroplasty group (13.2% vs. 22.4%, p = 0.05) [14]. However, in our study, the rate of delayed gastric emptying post-surgery was lower at 5.8%. A retrospective review of 50 studies by Ronald D.L. Akkerman et al. yielded similar findings, suggesting that esophagoplasty with the whole stomach increases the risk of delayed gastric emptying compared to gastric tube esophagoplasty [19]. Notably, factors such as intraoperative pyloric drainage, post-operative esophageal position (sternum or posterior mediastinum), and the location of the anastomosis (intrathoracic or cervical) did not significantly affect the incidence of gastric stasis post-surgery [19]. Delayed gastric emptying can significantly impact both short-term and long-term outcomes following surgery, particularly affecting the quality of life. In Frank Benedix's study involving 182 patients, where the rate of delayed gastric emptying was 39%, those experiencing delayed gastric emptying demonstrated prolonged hospital stays and increased incidence of postoperative complications such as pneumonia, despite no significant difference in mortality rates compared to those without delayed gastric emptying. In the long term, delayed gastric emptying can impair nutrient absorption, weight gain, and functional capacity, thereby impacting overall well-being and productivity [20].
The most widely proposed and debated preventive measure aimed at mitigating the occurrence of gastroparesis postoperatively involves intraoperative pyloric drainage, which encompasses techniques such as pyloric muscle opening, pyloroplasty, or Botox injection into the pyloric muscle. Across six randomized clinical trials and seven cohort studies comparing patients who underwent pyloric drainage with those who did not, it was observed that pyloric drainage failed to decrease the incidence of gastroparesis following esophagectomy [19]. Moreover, it was found to significantly elevate the risk of bile reflux and dumping syndrome [19]. However, Urschel et al. conducted a meta-analysis of studies comparing pyloric drainage versus non-drainage methods, revealing a significant reduction in gastroparesis risk within the pyloric drainage group, while other parameters such as anastomotic leak rate and respiratory complications remained unaffected [21]. Discrepancies among these studies arise from the lack of standardized diagnostic criteria for postoperative gastroparesis, alongside other influential factors like the method of esophagoplasty employed. In our study, none of the patients underwent pyloric drainage procedures, yet the incidence of gastric stasis was merely 5.4%.
One of the effective minimally invasive intervention methods recommended by numerous authors is endoscopic balloon dilation of the pylorus. In Jae-Hyn Kim's study (2008) involving 257 patients who underwent esophagectomy and gastric tube reconstruction between 2003 and 2006, 21 patients (8%) diagnosed with gastroparesis underwent pyloric dilation. Employing a balloon with an average diameter of 20 mm yielded positive outcomes, with clinical symptom improvement almost immediately post-intervention and favorable long-term results. Only 2 patients required a second dilation at 3 and 4 months post-initial treatment [22]. According to M. Lanuti (2011), out of 436 patients, 98 (22%) exhibited symptoms of postoperative gastroparesis, with 51 patients undergoing pyloric myotomy (52%). Among these, 38 patients (39%) underwent endoscopic balloon dilation with a success rate of 95%, while the remaining 60 patients were conservatively managed with medications to enhance motility, gastric decompression, or close monitoring [15]. Therefore, post-operative balloon dilation of the pylorus emerges as a positive and safe treatment method for patients with postoperative gastroparesis, even in those who have undergone pyloric drainage surgery.
According to E. Hadzijusufovic's retrospective study involving 115 patients undergoing esophagectomy utilizing the Ivor-Lewis method from 2015 to 2017, and divided into two groups – one with preoperative pyloric balloon dilation and the other without – those who underwent preoperative pyloric dilation exhibited lower rates of anastomotic leak, respiratory complications, and shorter hospital stays [23]. In our research, preoperative endoscopic balloon dilation of the pylorus was implemented in 37 patients undergoing thoracoscopic esophagectomy and whole stomach gastroplasty, resulting in success in 32 cases. In instances where postoperative pyloric circulation was assessed to be satisfactory, patients exhibited no symptoms of gastroparesis. Early nasogastric tube feeding commenced with incremental volume adjustments, while patient response and recovery time were closely monitored. The average duration until refeeding postoperatively was 5.2 days, with the earliest instance occurring on the 4th day postoperatively. Despite successful interventions, complications arose in 2 patients, involving gastroparesis, along with 2 cases of anastomotic leakage and 1 case of pneumonia necessitating prolonged mechanical ventilation, which hindered the evaluation of postoperative gastroparesis. The average postoperative follow-up period was 6.5 months, ranging from 1 to 14 months, during which no signs of gastric stasis were observed. Retrospectively reviewing existing medical literature revealed scant information regarding studies on the utilization of preoperative pylorus balloon dilation. Most studies primarily reported outcomes of postoperative pylorus balloon dilation when delayed gastric circulation occurred postoperative due to pyloric spasm.