Prophylactic pyloric drainage for prevention of delayed gastric conduit emptying following Ivor Lewis esophagectomy: a systematic review with exploratory synthesis

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BACKGROUND: DGCE complicates 10-50% of ILE and is associated with prolonged hospital stay, aspiration pneumonia, and impaired quality of life. Several intraoperative drainage techniques have been proposed, but the optimal prophylactic approach remains unclear. METHODS: We searched MEDLINE, Embase, Scopus, and Cochrane (PRISMA 2020; PROSPERO CRD420251025012; SWiM reporting guideline) for studies comparing intraoperative prophylactic pyloric drainage (pyloroplasty, botulinum toxin injection, pyloromyotomy, or mechanical balloon dilation) with no intervention in ILE. Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (non-randomized studies), and certainty of evidence was assessed using the GRADE framework. Pooled estimates were framed as exploratory. RESULTS: = 93.7%). Exploratory random-effects risk ratios versus no intervention were 0.28 (95% CI 0.03-2.24) for pyloroplasty (k = 3) and 0.71 (95% CI 0.48-1.05) for botulinum toxin (k = 3); excluding Cerfolio 2009 (POD-4 radiologic outcome incompatible with the other studies), the estimates were 0.07 (95% CI 0.01-0.59) and 0.99 (95% CI 0.54-1.81), respectively. Pyloromyotomy is reported in a single study and described narratively. Certainty of evidence (GRADE): very low. CONCLUSION: The current evidence is too sparse and heterogeneous to support routine intraoperative pyloric drainage in ILE. Use of standardized DGCE definitions and adequately powered ILE-restricted randomized trials is required.

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