Ann Thorac Surg 2007;83:728
© 2007 The Society of Thoracic Surgeons
Correspondence
Ischemic Preconditioning of the Gastric Conduit Prior to Esophageal Resection
C.S. Pramesh, MS, FRCS,
Rajesh C. Mistry, MS
Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012 India
(Email: cspramesh{at}vsnl.net; mistryrc{at}tmcmail.org).
To the Editor:
We read with interest Nguyen and colleagues’ [1] article on preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy in a recent issue of this journal. The study rekindles interest in the approach of "ischemic preconditioning" of the stomach to partial devascularization during esophagectomy. The theoretical background behind this strategy is that collateral vessels and anastomoses develop in response to ligation of the left gastric vessels, thereby reducing the incidence of gastric tube ischemia, which is undoubtedly the most dreaded complication after esophageal resection. Earlier studies failed to generate sufficient interest in this strategy primarily because of complications related to occlusion of the splenic artery leading to splenic abscesses and fever [2]. The authors avoid this complication by ligating only the left gastric vessels and sparing the splenic artery. This seems a sound strategy as the left gastric artery is the major vessel that is ligated at the time of esophageal resection and the contribution of the short gastric vessels and left gastroepiploic vessels is only marginal.
Alhough we agree in principle with the authors regarding this strategy, we have some queries regarding the actual methodology. If splenic artery occlusion is not done, why do the authors not perform preoperative embolization of the left gastric artery instead of laparoscopic ligation? This would achieve the same results as laparoscopic ligation of the left gastric vessels without the additional need for a surgical procedure. Even if diagnostic laparoscopy were routinely performed, it could be done at the same sitting as the primary surgery without having to do it as a second procedure after 10 to 12 days. Alhough this may need further formal evaluation, it seems to be a more cost-effective procedure and may spare patients the need for two operative procedures. Nevertheless, we commend the authors on their study and agree that a larger, prospective evaluation of ischemic preconditioning of the gastric conduit is warranted.
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References
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- Nguyen NT, Longoria M, Sabio A, et al. Preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy Ann Thorac Surg 2006;81:2318-2320.[Abstract/Free Full Text]
- Akiyama S, Kodera Y, Sekiguchi H, et al. Preoperative embolization therapy for esophageal operation J Surg Oncol 1998;69:219-223.[Medline]
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