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Eur J Cardiothorac Surg 2005;28:359
© 2005 Elsevier Science NL
Letter to the Editor |
Waikato Group of Hospitals, Waikato Hospitals, Hamilton, 2001 New Zealand
Received 29 March 2005; received in revised form 30 March 2005; accepted 28 April 2005.
* Tel.: +64 21 0771501; fax: +64 7 8398631. (Email: shkant101{at}yahoo.co.nz).
Key Words: Oesophageal Cancer
I read with interest the article by Dr Page Richard and colleagues [1] on surgical treatment of anastomotic leaks after oesophagectomy. Dr Page has given a full analytical report on various variables effecting anastomotic healing and suggested a clinical algorithm to follow.
In my clinical experiences for assessing various variable that effect healing of esophagogastric anastomosis, I found high Intragastric pressure and wall tension in gastric wall were independent risk factors leading to poor gastric muscosal perfusion and there by effecting anastomosis healing. I agree with Dr Page that anastomotic leak commonly occurs after first week of surgery and gastric tip or fundal necrosis is the commonest cause for anastomotic leak.
I aim to keep Intra-Gastric pressure low by continuous Naso-Gastric suction early and on passive drainage later in postoperative period [2]. Dr Page and colleagues would remove Naso-Gastric tube on day 2 of surgery and patient is orally fed on day 4 onwards. Moreover, I noted that gastric outlet drainage procedures were not routinely performed in this series. I think gastric outlet drainage procedure is a must not as a part of the procedure, but as a mean to achieve low Intra-Gastric pressure during early postoperative period. I think low Intra-Gastric pressure is as important as keeping low end diastolic pressure following Acute Myocardial Infarction. I would always do gastric outlet procedure even if it were a simple digital stretch, which hardly takes just a few minutes of surgical time and very little morbidity. By keeping Naso-Gastric tube on suction and then on free drainage combined with routinely done gastric outlet procedure, we aim to keep Intra-Gastric pressure low in early post operative period. Patient can be fed through Jejunostomy which is routinely performed as a part of procedure and taken out when anastomosis is secured commonly on 10th post operative day
I agree with Dr Page and colleagues that an early surgical intervention through a clean surgical field is a key for managing post-surgical anastomotic leak. I am sure that above-mentioned principle of maintaining low Intra-Gastric pressure during early post surgical period would help us to achieve satisfactory anastomotic healing.
I must congratulate Dr Page and colleagues the excellent work and adding some valuable guideline on managing post surgical anastomotic leak.
References
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