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Department of Thoracic Surgery, The Cancer Hospital of Fudan University, 27# Dongan Rd, Shanghai, 200032 China
(Email: hqchen1{at}yahoo.com).
We thank Drs Cooke and Calhoun [1] for their interest in our article [2].
The choice of anterior (retrosternal) or posterior (orthotopic) route for alimentary tract reconstruction after esophagectomy remains controversial. Although our study demonstrated the distance of anterior route is significantly shorter than the posterior route, we still believe that not only the length, but also various reasons should be taken into consideration when surgeons make their decision, including the characters of disease, location of the lesion, perioperative morbidity, mortality, recurrence patterns, and adjuvant chemotherapy, radiotherapy, or both.
In our institution, esophageal squamous cell cancer is almost the only disease that underwent esophagectomy and T3 stage, or more advanced patients who consist of a prominent portion (greater than 50%). Most of them had to receive adjuvant radiotherapy postoperatively. In addition, local and regional recurrence was not uncommon among these advanced patients. Wong and colleagues [3] reported recurrent tumor infiltration of the gastric conduit occurred in 14% of patients when the orthotopic route was used, and van Lanschot and colleagues [4] reported after potentially curative resection of esophageal cancer and prevertebral gastric tube reconstruction, approximately one-quarter of patients have secondary dysphagia develop due to locoregional recurrence [4]. Compared to the orthotopic route reconstruction, the retrosternal route reconstruction offers advantages, including avoidance of severe radiation damage to the gastric tube if postoperative radiation therapy is needed for residual disease and prevention of recurrent malignant dysphagia caused from a recurrent intrathoracic locoregional tumor mass invaded the neoesophagus. In consideration of these, we make the decision that the anterior (retrosternal) route is the preferable choice if there are no other contraindications.
Orringer and Sloan [5] reported that performing the Kocher maneuver could gain maximum mobility of the stomach and help reduce the tension of anastomosis, and with resection of the medial clavicle, sternoclavicular joint, and adjacent upper corner of the manubrium, it could widen the superior opening of the anterior mediastinum and provide better exposure of the cervical and upper thoracic esophagus, and prevent the obstruction of gastric conduit in the thoracic inlet [5]. But performing the Kocher maneuver has the potential risks of accidental massive bleeding and bile duct injury, and removal of the left sternoclavicular joint could cause early postoperative discomfort, which may accompany movement of the divided clavicle. In our practice, the Kocher maneuver was preformed in less than 1% of patients. We have found that the stomach can reach the neck for a cervical esophagogastric anastomosis without tension for virtually all patients. With our experience, the obstruction of gastric conduit by sternoclavicular joint has never been encountered and we acknowledge that in extremely rare situations, removal of the left sternoclavicular joint could widen the thoracic inlet space for gastric conduit to go through, but we do not believe it should be routinely carried out.
With respect to the comparison of postoperative morbidity, mortality between the anterior route reconstruction and posterior route reconstruction, there is little evidence to support the use of one route over the other. A meta-analysis of randomized controlled trials conducted by Urschel and colleagues [6] revealed that either approaches yielded similar outcomes. Orringer and colleagues [7] reported the incidence of cervical anastomotic leak with anterior route reconstruction that was unacceptably high, as 19% in one article [8], and 70% in another recently published article [7]. It has been hypothesized that when the esophageal substitute is not positioned within the normal posterior cervical esophageal bed, it lacks support from adjacent structures, which could result in a high rate of anastomotic leakage. However, it should be realized that in Orringer's studies [7,8], the number of patients recruited for both analyses is small (only 37 and 10 respectively), and in one of the articles, the retrosternal reconstruction was applied as palliative bypass procedure in patients with irresectable tumors and the esophagus was excluded, and most of the patients were in bad general condition [8]. So we believe it is hard to draw the conclusion that the high incidence of cervical anastomotic leakage is definitely associated with the anterior route reconstruction. Indeed, in our early practice we did find that the incidence of cervical anastomotic leak with anterior route reconstruction is as high as approximately 20%, much higher than with posterior route reconstruction. But after we carried out some modification, currently the incidence of neck anastomotic leak is dramatically decreased, which is less than 5%. A retrospective investigation with a large number of patients that was addressed in this issue is ongoing, and we will publish our finding soon.
Nuclear medicine assessment of gastric emptying was reported in three trails, but the methodology was different in each study. One showed similar function [9]. Another reported delayed emptying with anterior route reconstruction in the first minute of assessment [10]. The final trial reported delayed emptying with anterior route reconstruction at the 5-minute measurement, but equivalent emptying at the 30-minute measurement [4]. All three articles agreed that any observed differences in scintigraphic measurements were not clinically important. Contrarily, although we did not carry out the scintigraphic measurements of the gastric conduit, but by our clinical observation, the incidence of postoperative gastric retention was even lower with anterior route reconstruction, we suppose it was probably due to the mediastinal pleura restrict the over-expanding of gastric conduit, and we will design another large scale clinical trial to investigate this issue.
We agree with Cooke and Calhoun [1] that for patients with benign lesion, due to the long-life expectancy, it is conceivable that many of these patients will eventually develop primary cardiac disease and may require cardiac surgery in the future, the retrosternal neoesophagus could be an obstacle when the patients underwent cardiac surgery. For these patients, the anterior route reconstruction should be avoided.
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