Is pyloroplasty necessary in esophageal replacement by stomach? A prospective, randomized controlled trial.

A randomized, prospective, controlled trial compared the use of pyloroplasty (study group) with nonuse of the procedure (control group) in the treatment of 72 patients with carcinoma of the thoracic esophagus. In these patients, transthoracic esophagectomy was performed, and the whole stomach was used for reconstruction in the right side of the chest. No complications due to the pyloroplasty developed in any of the patients who underwent this procedure. Gastric emptying tests that were performed at the sixth postoperative month in 37 patients demonstrated a prolongation of emptying time in the control group (p less than 0.01). The patients' symptoms, however, did not correlate well with gastric emptying time. Follow-up assessment showed that a higher proportion of patients who did not undergo pyloroplasty suffered from symptoms of incomplete emptying while eating, but the difference was not statistically significant. Moreover, the proportion of patients who were free of postoperative symptoms gradually increased in both groups and reached 100% in the study group and 89% in the control group at 2 years. In the control group, two of the three patients with prolonged gastric emptying time complained of persistent regurgitation and distending discomfort after meals (18 and 24 months after surgery). They were the only two patients who might have benefited from a drainage procedure at the initial operation. Since there apparently were no reliable operative criteria by which to identify patients who might require drainage, and since the risk associated with pyloroplasty was negligible, it would seem reasonable to perform a pyloroplasty on every patient in whom the whole stomach was used for reconstruction after esophagectomy. This procedure would benefit the few patients who might manifest symptomatic gastric stasis.