Ann Thorac Surg 2002;74:1922-1923
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Invited commentary
Dorothea Liebermann-Meffert, MDa
a Department of Surgery, Klinikum rechts der Isar der Technischen, Universität München, Munich, Germany
Patients with leakage of an intrathoracic esophagogastric anastomosis are vitally endangered and need urgent surgical reintervention. Early detection improves the morbidity, if not the mortality rate after serious leakage. Prognostic factors therefore become increasingly important in the treatment of this complication.
In this simple and elegant study, the authors outline the modalities used for investigation of esophageal leakage and provide detailed and practical clinical information. They reported 47 consecutive patients who had esophageal cancer treated operatively according to a standard technique and surgical protocol. This included a stapler esophagogastrostomy between the gastric fundus and the stump of the esophagus resected in the upper mediastinum. In order to detect microcirculatory differences in the region of the esophagogastric anastomosis in all the patients, the authors positioned a nasogastric tube with a silicon balloon at the distal end in the gastric conduit. The balloon contained a tonocap device and monitored the mucosal partial carbon dioxide pressure (pCO2) continuously over 92 hours. The results were demonstrative and convincing: five of the authors’ 47 patients developed anastomotic leaks. In these patients the peak of the mean mucosal pCO2 was significantly higher than in patients without leaks and preceded clinical symptoms. Therewith, the technique seems a valid method of detecting microcirculatory changes early during the healing of the esophago–intestino anastomosis and attracts attention towards the approaching problem. One may regret that the authors do not give indications to discriminate between local hypoperfusion related to local gastric devascularization and a general problem related to a splanchnic hypoperfusion.
The method benefits from the anatomical fact that the gastric tube is supplied by the most serviceable of vessels, the right epiploic artery as shown by corrosion cast studies [1]. This vessel may or may not form an exterior macroscopic or an intramural microanastomosis with the left gastroepiploic artery. Although the blood supply to the stomach is superb, vessels peter out at the end of the gastric tube. Once the left gastric and short gastric vessels are ligated, the upper tube survives on microvascular connections that may be easily wrecked by traction, twisting, or manhandling. Dark oozing from a pale mucosal edge, petechial hemorrhages, and mottled serosa constitute damage of the circulation and augur poorly for healing without leak.
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References
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- Liebermann-Meffert D.M.I., Meier R., Siewert J.R. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992;54:1110.[Abstract/Free Full Text]
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