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A NOVEL ENDOSCOPIC PYLOROMYOTOMY TECHNIQUE FOR MINIMALLY INVASIVE ESOPHAGECTOMY
Cyril A. Boulila*1, Stéphane Renaud1, Yaseen Al-Lawati1, Karim Hasbini2, Joe Abou-Malhab2, Jose L. Ramirez-GarciaLuna1, Emma Lee2, Carmen L. Mueller1, Jonathan Spicer1, Juan-Carlos Molina1, Jonathan Cools-Lartigue1, Lorenzo E. Ferri1
1Medicine, McGill University, Montreal, QC, Canada; 2McGill University, Montreal, QC, Canada

INTRODUCTION: Pyloric drainage procedures, namely pyloromyotomy or pyloroplasty, have long been considered an integral aspect of esophagectomy. However, the requirement of pyloric drainage in the era of minimally invasive esophagectomy (MIE) has been brought into question. This is in part because of the technical challenges of performing the pyloric drainage laparoscopically, leading many surgical teams to explore other options or to abandon this procedure entirely. We have developed a novel, technically facile, endoscopic approach to pyloromyotomy, and sought to assess the efficacy of this new approach compared to the standard laparoscopic pyloromyotomy. METHODS: A prospectively maintained database of all esophagectomies at a high volume North American center were reviewed for those undergoing MIE, and compared those receiving endoscopic (EndoM) to laparoscopic (LapM) myotomy. EndoM was performed during the pre-incision gastroscopy with the IT-2 knife, initially designed for ESD, in three sites at the pylorus taking approximately 5 mins. Clinical variables assessed include age/sex, LOS, OR time, serosa injury requiring conversion to pyloroplasty, width of gastric conduit, and clinical surrogates of delayed gastric emptying (anastomotic leak, pneumonia, delay of PO feeding, and duration of NGTube). Data presented as median (IQR), Fisher's exact and Wilcoxon rank sum test determined significance, *p<0.05. RESULTS: Of 592 pts in the database, 83 had a MIE, 13 of which were EndoM and 70 LapM. There was no difference in age/sex between the two groups (EndoM 66.5(6.5) yrs 46% Male: LapM 66(14.3) yrs 62% Male). EndoM was associated with lower serosal injury (0/13 vs 28/70)* and a trend for shorter OR time (291(22.5) vs 310(60.0)mins)NS. Gastric conduit width did not differ (EndoM=4(1)cm vs LapM 4(1)cm). EndoM had shorter NGTube duration (2(0.25) vs 3(2)days)* but no difference in start of PO feeding (3(3.25) vs 3(3)). There were fewer complications with EndoM, specifically anastomotic leak (0/13 vs 10/70(14%))* and a trend for reduced pneumonia (1/13(7%) vs 14/70(20%))NS, translating into a shorter LOS (6 (1) vs 10 (8.5) days)*. CONCLUSIONS: We have described a novel endoscopic approach to pyloric drainage to be used in conjunction with Minimally Invasive Esophagectomy. We have shown that this technique is not only technically facile but also safe, and appears, in this preliminary series, to be more effective than laparoscopic pyloromyotomy at preventing clinical sequelae associated with delayed gastric emptying.


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