Manoop S. Bhutani, MD, FACG1, Shamim Ejaz, BS1, Irina M. Cazacu, MD1, Ben S. Singh, BA1, Mehnaz A. Shafi, MD, FACG2, John Stroehlein, MD, FACG1, Reza Mehran, MD, MSc1, Garrett Walsh, MD1, Ara A. Vaporciyan, MD1, Stephen Swisher, MD1, Wayne Hofstetter, MD1
1University of Texas MD Anderson Cancer Center, Houston, TX; 2MD Anderson Cancer Center, Houston, TX
Introduction: As patients with esophageal cancer undergoing esophagectomy have an improved survival over time, complications associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related adverse event which may cause debilitating symptoms, malnutrition and decreased quality of life. The aim of our study was to evaluate the effect of endoscopic intrapyloric BT injection combined associated with pyloric balloon dilation in patients with DGE after distal esophagectomy treated at a tertiary cancer center.
Methods: Patients with a prior history of esophageal cancer and distal esophagectomy who had undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study.100 units of BT were injected endoscopically into the pylorus in four quadrants using a standard needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12-20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed.
Results: A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. Baseline characteristics are summarized in Table 1. The patients underwent the procedures at a median of 22 months (range, 1-108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times.
Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. 18 patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) had shown no improvement, whereas in two (10 %) patients responses were not available.
Discussion: In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex and possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results.
Citation: Manoop S. Bhutani, MD, FACG; Shamim Ejaz, BS; Irina M. Cazacu, MD; Ben S. Singh, BA; Mehnaz A. Shafi, MD, FACG; John Stroehlein, MD, FACG; Reza Mehran, MD, MSc; Garrett Walsh, MD; Ara A. Vaporciyan, MD; Stephen Swisher, MD; Wayne Hofstetter, MD. P0286 - ENDOSCOPIC INTRAPYLORIC BOTULINUM TOXIN INJECTION WITH PYLORIC BALLOON DILATION FOR DELAYED GASTRIC EMPTYING AFTER DISTAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A 10-YEAR EXPERIENCE. Program No. P0286. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.