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Ann Thorac Surg 2005;80:447-448
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Invited commentary

Department of Thoracic Surgery, Royal Devon and Exeter NHS Trust, Barrack Rd, Exeter, EX2 5DW UK

(Email: richard.berrisford{at}rdehc-tr.swest.nhs.uk).

Lee and colleagues have highlighted for us the substantial proportion of patients (37.5% overall) whose gastric emptying is significantly delayed after esophagectomy with gastric interposition. Furthermore they have shown that gastric emptying improves with time as the stomach’s physiology recovers from the insult of surgery and vagotomy. Their discussion challenges us to consider the humoral and neural processes involved in gastric emptying, as well as the anatomical rearrangement inherent in gastric interposition.

They conclude that the shape of the stomach does not influence gastric emptying; there was no significant difference in emptying of the whole stomach (n = 34) and gastric tube (n = 16). This finding is at odds with a clinical impression that patients with a narrow gastric tube (3 to 5 cm) have less early satiety. This is a common opinion emerging from experience with minimally invasive gastric tube formation. We are not told the width of the gastric tube in the series published, but it is likely to be substantially wider than a narrow gastric tube.

The authors also suggest that the type of drainage procedure, pyloroplasty (n = 4) or finger disruption of the pylorus (n = 46) does not influence gastric emptying. The number of patients in the pyloroplasty group is insufficient to draw this conclusion. Furthermore the practice of performing any gastric drainage procedure at all is becoming less popular, with its inherent disadvantages of duodenogastric reflux and dumping. Without a control group of a "no drainage procedure," how do we know that finger disruption of the pylorus does not produce a swollen, dysfunctional sphincter that in itself delays gastric emptying in the early postoperative period in some patients?

We are reminded that previous studies have shown a lack of correlation between patients’ symptoms of early satiety and gastric emptying studies. The authors flag 8 of their patients who did have both symptoms and delayed gastric emptying studies. This small but important group of patients with symptoms at longer follow-up challenge us to improve their quality of life. These 8 patients underwent balloon dilatation of the pylorus. Only 4 had follow-up emptying studies and 2 of these were improved. So perhaps this is a worthwhile procedure in some patients. A randomized controlled trial of balloon dilatation in this group, with emptying studies before and after, would help further define its role. The authors’ practice did not include use of prokinetic agents, such as erythromycin, supported by the literature.

This article challenges us to improve the functional results of esophageal resection and should stimulate us to more precisely define the effect of gastric tube construction (ie, narrow, wide, whole stomach), gastric drainage (ie, none, pyloric disruption, pyloromyotomy, pyloroplasty), and postoperative treatments (ie, balloon dilatation and prokinetic agents).

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Berrisford, R. G. Search for Related Content PubMed PubMed Citation Articles by Berrisford, R. G.