Difficult Decisions in Thoracic Surgery - part 6 pdf

252 one patient (2%) was reported to die postoperatively from pulmonary aspiration In spite of the concerns raised regarding the risk of aspiration in the case series, the cohort studies and randomized, controlled trials not indicate a significantly higher risk of potentially fatal respiratory events when a gastric drainage procedure is not performed Interestingly, the two cohort studies that specifically addressed this issue both reported a slightly higher rate of aspiration when gastric drainage was performed The difference was not statistically significant Wang and coworkers20 reported signs or symptoms of aspiration in 17% of patients who had a gastric drainage procedure compared to only 3% when drainage was not performed Finley and colleagues24 reported an identical 17% frequency of aspiration in 249 patients who had a pyloroplasty compared to an 11% frequency of aspiration in the 46 patients who did not have a gastric drainage procedure The frequency of respiratory complications has been reported in two randomized, controlled trials In the first, Mannell and colleagues14 randomized 40 patients to reconstruction with and without a pyloroplasty Clinical outcome was assessed months after surgery Three patients in the no pyloroplasty group died of postoperative aspiration, with an additional death during late follow-up due to aspiration There were no major pulmonary complications early or late when a pyloroplasty was performed This difference in frequency of aspiration (20% without pyloroplasty vs 0% with pyloroplasty) did not reach statistical significance (p = 0.11), most likely due to the small number of patients randomized In the second randomized, controlled trial, Fok and associates16 randomized 200 patients each to pyloroplasty or gastric reconstruction without a drainage procedure Once again, pulmonary aspiration was more common in the no pyloroplasty group (including two deaths), but the difference did not reach statistical significance (23% vs 16%; χ2 = 1.56; p = 0.21) As a consequence, the meta-analysis by Urschell and coworkers15 found a nonsignificant reduction in pulmonary complications overall (RR = 0.69; 95% CI, 0.42–1.14; p = 0.15) and in fatal pulmonary aspiration (RR = 0.25; 95% CI, 0.4–1.6; p = 0.14) when a pyloroplasty was performed J.A Hagen and C.G Peyre 30.4 Impact on Diet Proponents of adding a gastric drainage procedure also express concern regarding the adverse effects of delayed gastric emptying on dietary function Early dietary function was assessed in the cohort study by Bemelman and colleagues30 that reported outcome in 140 patients following esophagectomy and reconstruction using the whole stomach in 40 patients (9 with and 31 without pyloroplasty), the distal stomach in 65 (20 with and 45 without pyloroplasty), and a narrow gastric tube without pyloroplasty in 35 patients When the time to resumption of a normal diet was assessed, they found no significant difference between patients with and without a gastric drainage procedure (6/29 vs 18/76; p = 0.80) Long-term dietary function was assessed in two of the randomized, controlled trials Cheung and colleagues22 randomized 35 patients to a pyloroplasty and 37 to reconstruction without gastric drainage At months, more patients in the pyloroplasty group were tolerating a regular diet (18/22 vs 17/25; p = 0.33) but this difference disappeared by years when all patients in both groups were tolerating a solid food diet A similar trend was seen when meal capacity was assessed, with a minor (nonsignificant) difference noted at months but with all patients in both groups tolerating a normal meal capacity by years Fok and coworkers16 have also compared the time to resumption of a normal diet in patients with and without gastric drainage At weeks, more patients in the gastric drainage group were taking a regular diet (65% vs 41%; p < 0.01), and the meal capacity was more likely to be normal (73% vs 52%; p < 0.01) While these authors also found that these differences decreased over time, there was still a significantly higher percentage of patients who complained of foregut symptoms during meals when a pyloroplasty was not performed (47% vs 14% at months; p < 0.01) 30.5 Impact of a Gastric Drainage Procedure on Gastric Emptying Formal assessment of gastric emptying after esophagectomy without gastric drainage was first reported by Angorn and colleagues.6 In this case 30 Gastric Emptying Procedures after Esophagectomy 253 TABLE 30.2 Evaluation of gastric emptying by radionuclide scintigraphy Author (year) Cheung22 (1987) Fok16 (1991) Gupta (1989) Kao (1994) Mannell14 (1990) Type of radionuclidelabeled meal Drainage (n) No drainage (n) Drainage (mean ± SD in min) No drainage (mean ± SD in min) p value Semi-solid Semi-solid Liquid Solid Solid 16 42 12 19 14 21 44 12 19 10 11.6 ± 9.6 6.5 ± 7.5 161.21 ± 3.10 175.9 ± 284 54 40.8 ± 38.0 24.3 ± 31.5 378.89 ± 26.16 250.6 ± 336 63