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a Department of General Surgery, Guy's and St Thomas' Hospital, NHS Foundation Trust, Lambeth Palace Rd, London, SE1 7EH United Kingdom
b Department of Respiratory Medicine, Guy's and St Thomas' Hospital, NHS Foundation Trust, Lambeth Palace Rd, London, SE1 7EH United Kingdom
c Department of Anesthesia, Guy's and St Thomas' Hospital, NHS Foundation Trust, Lambeth Palace Rd, London, SE1 7EH United Kingdom
(Email: robert.mason{at}gstt.nhs.uk).
We thank Hall and Older [1] for the interest in our article [2]. Prior to this study, there had been only one study evaluating cardiopulmonary exercise testing (CPX) in relation to esophagectomy, and this had shown that maximum oxygen consumption was correlated with postoperative morbidity [3]. Therefore, we utilized CPX testing alongside established measures of medical fitness to establish the use of both the anaerobic threshold and also the peak oxygen consumption in patients undergoing esophagectomy. Hall and Older [1] suggest that selection bias was present. The CPX testing was used only in the selection of patients for esophagectomy to back up the results of other tests and clinical suspicion that a patient might be unfit for major surgery. During this study we observed that patients who seemed to be medically fit on conventional measures performed unexpectedly poor during CPX testing. In this situation, we discussed treatment options with the patients, including continuing to perform surgery, but also other radical forms of treatment, such as definitive chemoradiotherapy. It is also worth noting that CPX testing has no role in assessing those patients with hepatic or renal dysfunction, which, in our experience, has been associated with a poor outcome after esophagectomy. We have collected data in our unit according to the reproducible definitions contained within the Common Terminology Criteria for Adverse Events v3.0 (CTCAE) criteria as this represents one of the main criticisms of many outcome studies after esophagectomy. We accept that it is important to distinguish between primary cardiopulmonary complications and secondary cardiopulmonary complications arising from location and nature of the surgery. It is accepted that surgical complications after esophagectomy often first present with a cardiopulmonary event. However, trying to arbitrarily separate complications, as suggested by Hall and Older, risks introducing bias. They point to the example of atelectasis, but conversely, postoperative atrial fibrillation has multiple causes and can not always be readily grouped as a primary or secondary problem. Hall and Older [1] make a valid point that patients with an anaerobic threshold less than 11 mL/min/kg seem to be better able to cope with postoperative complications.
We thank Prentis and colleagues [4] for their interest in our article [2]. We agree that the group of patients in our study was a predominantly cardiorespiratory fit population as evidenced by their mean anaerobic threshold. This group was recruited during a 2
-year period, which demonstrates the difficulties in performing studies of suitable size in this patient population. However, to test the utility of CPX by recruiting more unfit patients and subjecting them to an esophagectomy, when these patients might be more appropriately treated by nonsurgical radical treatments, such as chemoradiotherapy, raises ethical dilemmas. The true association between CPX and postoperative cardiopulmonary morbidity, and the need for intensive care unit resources, can only be tested in larger multicenter studies with consistent postoperative data collection. The "internationally recognized" anaerobic threshold cut off of 11 mL/min/kg was originally defined in a heterogeneous patient population undergoing a variety of surgical procedures; therefore, the appropriate cut off in patients undergoing esophagectomy might well be different. Indeed, we would agree that the value of AT compared with other measures derived from CPX requires further investigation.
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