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Eur J Cardiothorac Surg 2007;32:552. doi:10.1016/j.ejcts.2007.05.010
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Gastric outlet obstruction and respiratory complications after esophagectomy

Richard D. Page*, Michael J. Shackcloth

Department of Thoracic Surgery, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, United Kingdom

Received 10 May 2007; accepted 16 May 2007.

* Corresponding author. Tel.: +44 151 228 1616. (Email: richard.page{at}ctc.nhs.uk).

Key Words: Esophagectomy • Esophageal cancer • Respiratory complications

Lanuti and colleagues [1] are to be congratulated on their careful study of this difficult and controversial topic, which always leads to a heated discussion at esophageal meetings. Our approach is exactly the same as the authors, in that we only carry out a gastric drainage after esophagectomy with gastric reconstruction should the pylorus prove to be scarred and narrowed. Our impression is that most experienced esophageal surgeons take the same approach given the conflicting clinical evidence.

We would like to highlight another aspect of the early management of these patients in preventing the respiratory complications which the authors allude to when discussing the pros and cons of gastric drainage, namely the use of a nasogastric tube to keep the stomach empty. A particular problem of esophageal reconstruction is that when the mobilized stomach is placed transpleurally it is subjected to the negative intrathoracic pressure. As the patient swallows the stomach tends to dilate with air at the expense of the lung which can collapse. In addition to the problem of atelectasis, this leads to the added potential for respiratory aspiration of gastric contents which as we have recently shown [2] is universal after esophagectomy. We have also shown that nasogastric drainage of the mobilized stomach reduces this aspiration, although none of our patients were subjected to a gastric drainage procedure. As the patients’ lungs recover from surgery they show less tendency to collapse allowing the stomach to stay empty. As a result of our findings we have changed our practice to maintain nasogastric drainage for up to a week after surgery. In addition to a reduction in respiratory complications, we feel that the patients are able to resume oral intake with less clinical gastric outlet obstruction.

Footnotes

\#9734; The authors of the original paper [1] were invited to comment on this Letter to the Editor but felt that a reply was not necessary.

References

  1. Lanuti M, DeDelva PE, Wright CD, Gaissert HA, Wain JC, Donahue DM, Allan JS, Mathisen DJ. Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation. Eur J Cardiothorac Surg 2007;31(2):149-153.[Abstract/Free Full Text]
  2. Shackcloth MJ, McCarron E, Kendall J, Russell GN, Pennefather SH, Tran J, Page RD. Randomised clinical trial to determine the effect of nasogastric drainage on tracheal acid aspiration following oesophagectomy. Br J Surg 2006;93:547-552.[CrossRef][Medline]




This Article
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