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Division of Cardiothoracic Surgery, University of California, Davis Medical Center, 2221 Stockton Blvd, Room 2112, Sacramento, CA 95817-2214
(Email: davidt.cooke{at}ucdmc.ucdavis.edu).
Chen and colleagues [1] should be commended for an interesting study. However, after measuring a single outcome, the substernal route may be shorter then the posterior mediastinal route as measured from a fixed pylorus to the cricoid cartilage, the authors make a leap to the definitive statement: "[esophageal] reconstruction by means of [anterior route] AR after esophagectomy should be considered as the preferable route if there are no other contraindications." The authors assume that distance is the only relevant factor when considering either the substernal or posterior mediastinal route for esophageal reconstruction. Although the longer distance of the posterior mediastinal route may add tension to the cervical anastomosis of a gastric pull-up, this tension is eliminated by performing a Kocher maneuver. By performing the Kocher maneuver, the gastric conduit is afforded enough redundancy in which the pylorus can be brought up to the plane of the xiphoid process. As a result, most, if not all gastric conduits can be brought up through the posterior mediastinum into the neck without tension. The authors refer to the Kocher maneuver as an "unnecessary surgical procedure," yet the Kocher maneuver is a basic surgical principle with little morbidity.
In addition, the authors do not comment on the fact that for the substernal route, the thoracic inlet needs to be widened. To prevent obstruction of the substernal gastric conduit by the head of the left clavicle, the left sternoclavicular joint should be resected [2, 3]. In our own experience, we have had to resect the left sternoclavicular joint in a patient who presented with proximal dysphagia several years after transhiatal esophagectomy, performed at another institution, with substernal gastric pull-up for esophageal cancer. Resection of the patient's sternoclavicular joint relieved the dysphagia.
Finally, for patients undergoing esophagectomy for benign disease, high grade dysplasia, superficial carcinomas, and complete pathologic response after neoadjuvant therapy, long-term survival is expected. For the previously mentioned patients, it is conceivable that many of them will eventually develop primary cardiac disease and require cardiac surgery (ie, coronary artery bypass grafting, valve repair, or replacement, or a combination of the above). The substernal gastric conduit makes cardiac surgery unnecessarily complex and case reportable [4, 5].
In conclusion, for the previously mentioned points alone, esophageal reconstruction with a gastric conduit through the posterior mediastinum should remain the preferred route. However, for cases of delayed esophageal reconstruction after esophageal discontinuity (eg, caustic ingestion) in which the posterior mediastinum is obliterated, the substernal route is a valuable alternative. We await with interest the multicenter, randomized clinical trial the authors mention in their "Comment" section.
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  J. Zhou and H. Chen Reply. Ann. Thorac. Surg., October 1, 2009; 88(4): 1391 - 1392. [Full Text] [PDF]
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