Intra-operative pyloric BOTOX injection versus pyloric surgery for prevention of delayed gastric emptying after esophagectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after esophagectomy. BOTOX injections and pyloric surgeries (PS), including pyloroplasty (PP) and pyloromyotomy (PM), are performed intraoperatively as prophylaxis against DGE. This study compares the effects of pyloric BOTOX injection and PS for preventing DGE post-esophagectomy. METHODS: We retrospectively reviewed Moffitt's IRB-approved database of 1364 esophagectomies, identifying 475 patients receiving BOTOX or PS during esophageal resection. PS was further divided into PP and PM. Demographics, clinical characteristics, and postoperative outcomes were compared using Chi-Square, Fisher's exact test, Wilcoxon rank-sum, and ANOVA. Propensity-score matching was performed between BOTOX and PP cohorts. RESULTS: 238 patients received BOTOX, 108 received PP, and 129 received PM. Most BOTOX patients underwent fully minimally invasive robotic Ivor-Lewis esophagectomy (81.1% vs 1.7%) while most PS patients underwent hybrid open/Robotic Ivor-Lewis esophagectomy (95.7% vs 13.0%). Anastomotic leak (p = 0.57) and pneumonia (p = 0.75) were comparable between groups. However, PS experienced lower DGE rates (15.9% vs 9.3%; p = 0.04) while BOTOX patients had less postoperative weight loss (9.7 vs 11.45 kg; p = 0.02). After separating PP from PM, leak (p = 0.72) and pneumonia (p = 0.07) rates remained similar. However, PP patients had the lowest DGE incidence (1.9% vs 15.7% vs 15.9%; p = < 0.001) and the highest bile reflux rates (2.8% vs 0% vs 0.4%; p = 0.04). Between matched cohorts of 91 patients, PP had lower DGE rates (18.7% vs 1.1%; p = < 0.001) and less weight loss (9.8 vs 11.4 kg; p = < 0.001). Other complications were comparable (all p > 0.05). BOTOX was consistently associated with shorter LOS compared to PS (all p = < 0.001). CONCLUSION: PP demonstrates lower rates of DGE in unmatched and matched analyses. Compared to BOTOX, PS is linked to reduced DGE rates. While BOTOX is associated with more favorable LOS, this may be attributable to difference in operative approach. PP improves DGE rates after esophagectomy without improving other postoperative complications.

Surgical Aortic Valve Replacement in the Setting of Anomalous Circumflex Coronary Artery.

BACKGROUND: The anomalous circumflex coronary artery (ACCA) from the right coronary artery or sinus of Valsalva lies in proximity to the aortic valve annulus. This study sought to determine the prevalence of injury to the ACCA during surgical aortic valve replacement (SAVR). METHODS: We queried the databases of the Departments of Cardiovascular Surgery and Cardiovascular Diseases of Mayo Clinic, Rochester, Minnesota for all patients who underwent SAVR in the setting of an ACCA. The study investigators identified 31 patients operated on from September 2002 through December 2018. The end point was myocardial ischemia in the distribution of the ACCA. RESULTS: The patients' mean age was 69 ± 11 years, sex was female in 8 patients (26%), and ejection fraction was 62% (interquartile range, 59% to 68%). No patient underwent exploration of the ACCA, but 5 (16%) had a coronary artery bypass graft to the ACCA. No patient demonstrated myocardial infarction or underwent perioperative intervention on the ACCA; however, discharge echocardiography showed new lateral wall motion abnormality in 5 (16%) patients that was associated with a reduction in ejection fraction of -11% from baseline (P = .007). Coronary artery bypass graft to the ACCA was not protective of new lateral wall motion abnormality (P = .968). Mortality was 34% ± 10% at 10 years and was not associated with new lateral wall motion abnormality (log-rank test P = .183). CONCLUSIONS: Clinically apparent myocardial infarction was not identified after SAVR, but echocardiographic evidence of myocardial ischemia in the distribution of the ACCA was identified in 16% of patients. Protective adjuvant intervention on the ACCA may be indicated. Further study is warranted.