Prophylactic Pyloric Dilatation and its Impact on Early Delayed Gastric Conduit Emptying and Pneumonia Post-esophagectomy: A Multi-centre Cohort Study

Abstract Background Early delayed gastric conduit emptying (DGCE) and pneumonia are among the most common complications following oesophagectomy. These issues can be challenging to address during minimally invasive surgery with pyloroplasty or pyloromyotomy. This study evaluated the impact of prophylactic endoscopic pyloric balloon dilatation (PBD) on early postoperative outcomes. Methods Consecutive patients undergoing oesophagectomy with gastric conduit reconstruction for cancer at two Australian tertiary centres (2017–2025) were retrospectively analysed. From 2023, intraoperative endoscopic-assisted PBD using a 20 mm balloon inflated for two minutes across the pylorus was adopted as standard practice. Primary endpoints were early DGCE and hospital-acquired pneumonia (HAP) within 30 days; secondary endpoints included nasogastric tube (NGT) output and duration, and hospital length-of-stay. Associations were examined using multivariable logistic regression and inverse-probability-weighted regression adjustment (IPWRA). Results Of 187 patients, 40 (21.4%) received PBD. Compared with controls, PBD was associated with reduced DGCE (15% vs. 40.1%; odds ratio [OR] 0.26, 95% confidence interval [CI] 0.11–0.65) and HAP (20% vs. 40.8%; OR 0.36, 95% CI 0.17–0.80). Pyloric balloon dilatation independently predicted lower DGCE (OR 0.33, 95% CI 0.12–0.91) and HAP (OR 0.18, 95% CI 0.05–0.67), with absolute risk reductions of 27.4% and 30.8% respectively on IPWRA analysis. Pyloric balloon dilatation was also associated with lower postoperative NGT outputs, earlier NGT removal (median 6 [interquartile range (IQR) 4-11] vs. 4 [IQR 3–7] days; p = 0.032), and shorter hospital length of stay (median 13 [IQR 9–22] vs. 9 [IQR 8–16] days; p = 0.007). Conclusions Prophylactic PBD was associated with lower early DGCE and pneumonia. This enabled earlier nasogastric tube removal and shorter hospital stay, supporting its integration into contemporary practice.