A 52-year-old man with a malignant esophageal tumor underwent near-total esophagectomy
with gastric replacement and feeding jejunostomy. Pyloroplasty was not performed.
The postoperative course was unremarkable, except for excessive drainage from the
nasogastric tube of 1000 - 1300 ml per day from the first postoperative day.
Eight days later, a thick discharge appeared from the thoracic drain and 700 - 800
ml was drained per day without any change in the patient’s clinical condition. A barium
meal demonstrated a leak from the cervical anastomosis, gastric dilatation with a
large amount of fluid content, and very slow gastric emptying. Esophagogastroduodenoscopy
revealed a 1-cm hole 2 cm distal to the anastomosis, with a plastic drain emerging
from it. The pylorus was dilated pneumatically with an 18-mm through-the-scope (TTS)
balloon dilator in order to enhance gastric emptying. The drain was withdrawn by 2
cm.
Ten days later, fluid discharge from the thoracic drain had ceased completely, but
the nasogastric tube was still draining 600 - 1100 ml per day. On the 37th postoperative
day, because there was no improvement in the delayed gastric emptying, 80 IU of botulinum
toxin (Botox; Allergan Pharmaceuticals, Westport, Co. Mayo, Ireland) was injected
into the pylorus (20 IU into each quadrant). Three days after this procedure, drainage
from the nasogastric tube ceased completely. A barium meal demonstrated normal evacuation
of gastric content into the duodenum. Oral feeding was resumed gradually and the patient
was discharged from hospital in a satisfactory condition. He remained asymptomatic
during 6 months of follow-up.
After total esophagectomy with gastric cervical anastomosis the denervated thoracic
stomach acts mainly as a tube conduit and empties by gravity alone [1]. It seems that the spastic pylorus delays effective gastric emptying and pyloric
drainage procedures may be a solution. Resolution of this complication is usually
spontaneous. In patients in whom resolution is delayed, the ideal would be to perform
a minimally invasive procedure to bridge this delay until spontaneous improvement
occurs. We decided to try the injection of botulinum toxin into the pylorus, and this
eventually proved successful. To the best of our knowledge, this is the first report
of the use of botulinum toxin injection for the treatment of gastroparesis following
esophagectomy.
Competing interests: None
Endoscopy_UCTN_Code_TTT_1AO_2AM
