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Ann Thorac Surg 2000;70:1655
© 2000 The Society of Thoracic Surgeons

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Discussion

Discussion

Discussion

DR JOSEPH B. ZWISCHENBERGER (Galveston, TX): The Mayo Clinic group is to be congratulated for their honest reporting on such a difficult group of patients and on their attempt to define and quantify functional outcome. However, I am intrigued by your ability to retrospectively review charts months to decades old and assign an outcome value for statistical evaluation. In one of your concluding slides, how did you compare functional outcome to the different parameters that you studied?

DR YOUNG: We looked at medications, dilatations, and symptoms. We do have another study that we are doing now that is more prospective that will be a better tool to look at quality of life.

DR ZWISCHENBERGER: So you did have patient contact on each questionnaire?

DR YOUNG: Yes.

DR ZWISCHENBERGER: What was the length of follow-up? You mentioned between months and decades, so I was wondering at what point you determined you would ask them their outcome—weeks, months, years, decades?

DR YOUNG: The patient population had to be out of the surgery at least 1 month, and then we had the charts in front of us with the follow-up visits, and anybody before a month was excluded in the functional outcome studied up to 1997.

DR JOSEPH I. MILLER (Atlanta, GA): I congratulate Dr Young and the Mayo Clinic group on a very well prepared talk and manuscript, as always. I also appreciated the opportunity to review the manuscript. There are several important points that I think that this study points out.

First, most of us in this room grew up during the age of colonic interposition where the dictum was colon for benign disease, stomach for malignant disease. That started with the large series from Postlewaite at Duke, then also Wilkins at the Massachusetts General and Mansour at Emory. Again, through the 1960s, 1970s, and 1980s one almost always tried to use colon. It was in the 1990s that Mark Orringer started talking about esophageal replacement using the stomach, and I think we have sort of come back to that.

In looking at your series over a 41-year period of time, it is interesting that you have about a third, roughly, that were stomach, and it looked like most of those were done through a laparotomy and cervical approach. Also it is interesting to note that you had two adverse statistically significant things affecting outcome: one was a cervical anastomosis and then the other is the route of transplantation.

I think this points out, and your study points out, that a cervical anastomosis is not a benign anastomosis. Most good series with high intrathoracic anastomosis report a leak rate below 1%; even the original leak rate in Orringer’s series was 15%, now down to 2.5%. But I think it points out that, first, just because you can get the stomach to the neck, it is not a benign anastomosis; and, second, I think the other thing your study points out is the technical difficulty of reoperation at the gastroesophageal junction. Frequently you go there and you can’t get through the hiatus on a reoperation and you have got to look for another route of transplantation where you want to go to the right chest or the left chest, and then the surgeon sort of makes his own route depending on the conduit. I thank you for the opportunity of reviewing this. Thank you.

DR CHRISTOPHER J. KNOTT-CRAIG (Oklahoma City, OK): I too rise to congratulate the Mayo Clinic for this wonderful presentation and excellent results with a very difficult group of patients. Have you changed your technique or do you have any advice in terms of how to minimize the necessity for recurrent dilatations in a cervical anastomosis? And secondly, I was intrigued to see that the oldest patient you operated on was 100 years old; and I would like to ask you what kind of repair you did in that patient.

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