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Ann Thorac Surg 2003;75:634-635
© 2003 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Jacobi Medical Center, 1400 Pelham Parkway South, Room 510, Bronx, NY 10461, USA
To the Editor:
The article by Avendano and colleagues [1] reviews a series of 61 patients from a group of 96 who underwent esophagectomy for malignancy during a recent 6-year period. In a paper looking for this information it is important to know what approaches were used for the operation: three holes? Ivor Lewis? transhiatal? Other? There is no presentation of these data eventhough at one point the authors indicate that "transhiatal esophagectomy was considered the preferred route for resection of esophageal cancer for patients who were believed to be at increased risk for pulmonary complications." However an earlier paper by Sugimachi and coworkers [2] clearly implicates surgical disruption of the retroesophageal vagal plexus, situated mainly around the trachea, for postoperative pulmonary complications. This disruption according to Sugimachi interfers with the cough mechanisms preventing the patient from clearing his airway. Patients with poor pulmonary function should be the last ones to have a transhiatal resection when disruption of these plexuses is more likely to occur. Furthermore, 60% of patients in this series were operated on for adenocarcinomas when frequently a distal esophagectomy through a left thoraco or thoracoabdominal approach suffices for these low tumors. At the same time this approach interferes less with the patient’s respiratory function.
Another pulmonary complication reported by the authors relates to pleural effusions observed in 86.9% of their cases. We however consider pleural effusion to be related to the esophageal resection per se and would not list this as a pulmonary complication.
We would also like to know if any decompression of the transposed viscus was used by the authors to avoid pulmonary complications, which are frequently associated with aspiration in the immediate postsurgery period. The use of nasogastric tubes positioned through the cricopharingeus can also facilitate aspiration of gastrointestinal contents into the airway. In order to eliminate this possibility "nasogastric" tubes should be positioned through a transcervical approach directly into the pulled-up stomach or colon as we recently described [3].
The authors compare postoperative pulmonary complications in patients with preoperative values of FEV1 above and below 65% of predicted values, concluding that patients with lower FEV1 had more complications than those with higher FEV1.
They also compare patients who had preoperative chemotherapy, combined chemoradiotherapy, or no neoadjuvant therapy preceding surgery. In this analysis there is no reference to what chemotherapeutic agents were used or what radiation protocol was employed. The authors conclude that preoperative chemoradiotherapy increased the incidence of pulmonary complications, which was not observed when only chemotherapy was used. Was radiotherapy found to have a longer survival advantage? Certainly neoadjuvant therapies depend on answers to this question.
It is not clear and the authors should elaborate as to why a group of 61 patients was selected for their study from 96 patients who were identified as having undergone an esophagectomy during the period covered by this paper.
In this interesting paper some necessary clarifications will enhance the message and possibly suggest what surgical technique is better tolerated from a pulmonary point of view.
References
This article has been cited by other articles:
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  F. Leo, N. Venissac, R. Palihovici, F. L. Faso, and J. Mouroux Aristotle, esophagectomy, and pulmonary complications Ann. Thorac. Surg., April 1, 2004; 77(4): 1503 - 1503. [Full Text] [PDF]
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