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J Thorac Cardiovasc Surg 2000;119:1298-1299
© 2000 The American Association for Thoracic Surgery
LETTERS TO THE EDITOR |
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195
To the Editor:
We read with great interest the article by Johansson and associates titled "Pharyngeal Reflux After Gastric Pull-up Esophagectomy With Neck and Chest Anastomoses."
1 This topic is important, controversial, and difficult to study, and the authors are to be commended for addressing it.
The study design is flawed. It is not clear whether the groups are similar in tumor stage, demographics, and other variables that could influence pharyngeal reflux. The type and complexity of the resections are not specified. Reconstructions are atypical and variable. No gastric drainage procedures were performed; thus the occurrence of gastric retention, reflux, and reflux-related complications may have been increased. Construction of the gastric tubes varied between the two groups, with additional staplings in the thoracic group. This additional gastric resection resulted in smaller gastric remnants in the thoracic group. Equivalent anastomotic techniques were not used in the chest and neck. The occurrence of anastomotic complications, types of complications, and associated morbidity were not addressed.
The pH measurements may be inaccurate if the pH probe was positioned with endoscopic verification during only the initial measurement. Since esophageal pH measurements in the cervical group were obtained at a mean of 3.6 cm closer to the neo-gastroesophageal junction than in those with thoracic anastomoses, imprecision in pH probe placement at later study times could account both for the large variability in pH measurements and the perceived increase in acid exposure over time.
Although Johansson and associates imply that cervical anastomoses are inferior to thoracic anastomoses, their results do not support this conclusion. The wide confidence intervals of the groups overlap in all variables assessed; statistically, the groups are equivalent. The statistical analysis demonstrates only that the patterns of reflux are different. It does not directly demonstrate a difference in pharyngeal acid exposure between the groups. In addition, the trend was toward fewer anastomotic strictures, fewer dilations, and decreased occurrence and severity of esophagitis in the patients undergoing a cervical anastomosis. At 1 year, none of the patients with a cervical anastomosis had these problems. Symptomatic complaints were also less common in the cervical group at 1 year.
The data of Johansson and associates suggest comparable or superior results after cervical anastomosis. Combined with previously documented advantages of cervical anastomosis (minimal mortality with anastomotic leak, avoidance of thoracotomy with transhiatal approach), these results support cervical anastomosis during esophageal reconstruction as the preferred method for restoration of esophagogastric continuity.
12/8/106037 doi:10.1067/mtc.2000.106037
References
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