Pyloroplasty During MIE/RAMIE: Annals of Surgery | April 2026

Introduction

Minimally invasive esophagectomy (MIE) and robot-assisted MIE (RAMIE) are standard approaches in the treatment of Esophageal cancer. One debated step during surgery is whether to perform pyloroplasty, a procedure intended to improve gastric emptying after esophageal resection. Despite widespread use, high-quality evidence supporting or refuting its benefit has been limited, especially in the modern minimally invasive era.

Problem Statement

There is a lack of level-1 evidence to determine whether adding pyloroplasty during MIE or RAMIE improves postoperative outcomes.

Summary

This phase III randomized controlled trial provides important evidence supporting the use of pyloroplasty during minimally invasive esophagectomy. The study used an adaptive design and demonstrated that patients undergoing pyloroplasty had better short-term outcomes compared to those without it.

The primary composite outcome—pneumonia or anastomotic leak requiring surgery—occurred less frequently in the pyloroplasty group (18%) compared to the no-pyloroplasty group (27%). The trial was stopped early once predefined superiority criteria were met, indicating a high probability that pyloroplasty improves short-term outcomes.

Clinically, this suggests that pyloroplasty may reduce postoperative complications, particularly respiratory and anastomotic issues, in patients undergoing MIE or RAMIE. However, long-term outcomes and quality-of-life data are still awaited.

Key takeaway: Adding pyloroplasty during minimally invasive esophagectomy improves short-term surgical outcomes and may be considered a beneficial adjunct procedure.