Ann Thorac Surg 2007;83:1278
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Eddie L. Hoover, MD
State University of New York-Buffalo, Department of Surgery (112), Veterans Affairs Medical Center-Buffalo, 3495 Bailey Ave, Buffalo, NY 14215
(Email: eddie.hoover{at}med.va.gov).
Motoyama and colleagues [1] report their experience with 34 patients treated with colon interposition through the posterior mediastinal route as opposed to the substernal route because of prior gastric resections or because of synchronous malignant lesions in the esophagus and stomach. They conclude that this procedure could be preformed at low risk, without mortality and with long-term outcomes that compare favorably with other approaches with respect to chewing and swallowing, active peristalsis, and a lower incidence of long-term reflux, especially when an ileocecal-right colon graft was used.
Later in their series, they discontinued doing angiograms in these patients as being unnecessary, and I agree. I also agree with their preference for the ileocecal-right colon as being simpler and providing for more length without tension. They note that colon interposition is safe "in high-volume centers," but do not provide data defining what constitutes high volume. I would add here that each surgeon must make an honest determination about his or her ability to perform this procedure, since fewer esophageal resections are being done at most centers in lieu of alternative therapies. After all, the patient only gets one opportunity for the surgeon to get this right. Motoyama and colleagues used microvascular surgery in 2 patients in whom the colon had become ischemic, with good recovery in both. I think that it is very important to have this kind of capability available, and the microvascular team should be involved in the preoperative planning process. These procedures are rare events even for high-volume centers, and most thoracic surgeons will have limited experience with intra-abdominal procedures. Therefore, I would strongly urge that an experienced general or colorectal surgeon be involved with the mobilization of the colon.
Motoyama and colleagues used a stapling device for the proximal anastomosis on occasion without providing criteria or a technical schematic, and I would caution surgeons to be very careful here, because one must have enough esophagus beyond the level of the laryngeal cartilage for the stapler to engage and produce two intact donut rings. I disagree with their recommendation for annual endoscopy and would follow standard guidelines for surveillance endoscopy for colorectal disease, absent any pathology on the previous study.
The authors’ results were remarkable, especially in the cohort of patients (n = 19 of 34) who had stage III/IV disease, with a 5-year survival rate of 48%. Eight patients had stage IV disease preoperatively, and I probably would not have operated upon this group absent almost total dysphagia or poor candidacy for either laser ablation or stent placement, or both, especially if they had hepatic metastasis, which was not specified in the manuscript.
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References
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- Motoyama S, Kitamura M, Saito R, et al. Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal cancer Ann Thorac Surg 2007;83:1273-1278.[Abstract/Free Full Text]
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Surgical Outcome of Colon Interposition by the Posterior Mediastinal Route for Thoracic Esophageal Cancer
- Satoru Motoyama, Michihiko Kitamura, Reijiro Saito, Kiyotomi Maruyama, Yusuke Sato, Kaori Hayashi, Hajime Saito, Yoshihiro Minamiya, and Jun-ichi Ogawa
Ann. Thorac. Surg. 2007 83: 1273-1278.
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