**Background:** Delayed gastric conduit emptying (DGCE) after esophagectomy is associated with increased postoperative complications and prolonged hospital stay. Standardized clinical pathways, including early upper gastrointestinal (GI) contrast studies, may improve outcomes. This study aimed to assess gastric conduit emptying using a routine contrast study protocol and evaluate its impact on nasogastric tube management, complications, and length of stay.
**Methods:** A prospective cohort was conducted at two high-volume esophageal surgery centers (Virginia Mason Medical Center, Seattle, and Karolinska University Hospital, Stockholm) from June 2019 to February 2021. All patients undergoing esophagectomy with gastric conduit reconstruction were included. The standardized protocol included an upper GI contrast study on postoperative day 2 or 3. Patients swallowed 50 ml of water-soluble contrast followed by 50 ml of water; digital spot fluoroscopic images were taken at 1, 2, and 5 minutes. Conduit emptying was classified as: Level 1 (complete/near-complete), Level 2 (partial), or Level 3 (no/minimal emptying, defined as DGCE). A single expert radiologist, blinded to outcomes, reviewed all images. For Level 3, a treatment protocol was initiated: nasogastric tube kept in place, erythromycin 40 mg every 8 hours, repeat contrast study in 24-36 hours; if persistent, endoscopic pyloric dilation with Botox injection was performed. Primary outcome was radiological level of emptying. Secondary outcomes included days with nasogastric tube, length of hospital stay, overall complications (Esophagectomy Complication Consensus Group definitions), severe complications (Clavien-Dindo), pulmonary complications, anastomotic leak, and ICU stay.
**Key Results:** Of 119 patients, 112 (94.1%) completed the contrast study. Median age was 69 years (IQR 61-74), 81.5% were male, 98.3% had esophageal cancer, and 76.5% underwent minimally invasive surgery. Emptying grades: Level 1 in 70 (62.5%), Level 2 in 34 (30.4%), Level 3 in 8 (7.1%). Patients with Level 3 had significantly longer nasogastric tube duration (median 6 vs. 3 days, P<0.001) and longer hospital stay (median 17 vs. 9 days for Level 1 and 8 days for Level 2, P<0.001). Overall complications occurred in 100% of Level 3 patients vs. 54.3% (Level 1) and 61.8% (Level 2) (P=0.042). However, there were no significant differences in severe complications (Clavien-Dindo), pulmonary complications, pneumonia, ICU stay, or anastomotic leak. Logistic regression showed no increased risk of anastomotic leak for Level 3 vs. Level 2 (OR 0.92, 95% CI 0.15-5.50, P=0.930) or vs. Level 1 (OR 0.75, 95% CI 0.14-4.12, P=0.741). Conduit width was significantly smaller in Level 1 (median 2.7 cm) vs. Level 2 and 3 (both 3.3 cm, P=0.005).
**Clinical Implications:** This study demonstrates that a standardized upper GI contrast study on postoperative day 2-3 can objectively classify gastric conduit emptying after esophagectomy. DGCE (no emptying) occurred in only 7.1% of patients but was associated with significantly longer hospital stay and higher overall complication rates. Early identification allows targeted interventions (erythromycin, endoscopic dilation) that may prevent severe complications, as evidenced by the lack of increased severe complications or anastomotic leaks in the DGCE group. The protocol facilitates adherence to ERAS guidelines by enabling early nasogastric tube removal in patients with adequate emptying (Level 1 or 2), potentially reducing length of stay. The association between narrower conduit width and better emptying suggests that surgical technique (conduit construction) may be important. Limitations include lack of data on nasogastric output volumes and clinical symptoms of DGCE, and the need for validation in larger cohorts. Nonetheless, incorporating routine contrast studies into post-esophagectomy pathways provides objective criteria for management decisions and may improve outcomes.