Invited Commentary

Abstract

This study by Pham and colleagues [1Pham T.H. Perry K.A. Enestvedt K. et al.Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications.Ann Thorac Surg. 2011; 91: 380-386Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] describes an intraoperative method to assess gastric conduit perfusion during minimally invasive esophagectomy. The technique, intraoperative optical fiber spectroscopy (OFS), works in a fashion similar to the familiar oxygen saturation probe to determine the oxygenation of the blood within the stomach graft. Although used during minimally invasive esophagectomy in this study, OFS could be used during open esophagectomy as well. The authors found that decreased gastric conduit perfusion, as measured by OFS, was associated with increased anastomotic complication rates (leak, 26%; strictures, 13%). They hypothesize that steps could be taken in patients at risk to prevent gastric conduit ischemia and, therefore, anastomotic complications. In 4 patients in their series, the stomach graft was mobilized in advance to ischemic condition it. A nonsignificant trend towards improved graft oxygenation was noted and no leaks in this small set of patients.Since the beginning of esophageal resective operations, preventing anastomotic leaks and their potentially deadly consequences has been the holy grail of the esophageal surgeon. New technologies are developing that may resolve this issue once and for all. However, over the years, it has been the widespread adoption of the gastric conduit, refinement in anastomotic techniques (both hand sewn and stapled), and placement of the anastomosis in the neck, that have made the greatest impact on reducing both the incidence and consequences of leaks. Now, esophageal anastomotic leak rates of 1% to 2% or less are reported in large series. Many consider a leak rate of zero to be the attainable target. Furthermore, a cervical anastomotic leak can be managed by bedside drainage and dressings. The addition of an adjuvant jejunostomy even permits home enteral feeding until the leak spontaneously closes. I believe these methods remain the gold standard for reducing anastomotic complications. This study by Pham and colleagues [1Pham T.H. Perry K.A. Enestvedt K. et al.Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications.Ann Thorac Surg. 2011; 91: 380-386Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] describes an intraoperative method to assess gastric conduit perfusion during minimally invasive esophagectomy. The technique, intraoperative optical fiber spectroscopy (OFS), works in a fashion similar to the familiar oxygen saturation probe to determine the oxygenation of the blood within the stomach graft. Although used during minimally invasive esophagectomy in this study, OFS could be used during open esophagectomy as well. The authors found that decreased gastric conduit perfusion, as measured by OFS, was associated with increased anastomotic complication rates (leak, 26%; strictures, 13%). They hypothesize that steps could be taken in patients at risk to prevent gastric conduit ischemia and, therefore, anastomotic complications. In 4 patients in their series, the stomach graft was mobilized in advance to ischemic condition it. A nonsignificant trend towards improved graft oxygenation was noted and no leaks in this small set of patients. Since the beginning of esophageal resective operations, preventing anastomotic leaks and their potentially deadly consequences has been the holy grail of the esophageal surgeon. New technologies are developing that may resolve this issue once and for all. However, over the years, it has been the widespread adoption of the gastric conduit, refinement in anastomotic techniques (both hand sewn and stapled), and placement of the anastomosis in the neck, that have made the greatest impact on reducing both the incidence and consequences of leaks. Now, esophageal anastomotic leak rates of 1% to 2% or less are reported in large series. Many consider a leak rate of zero to be the attainable target. Furthermore, a cervical anastomotic leak can be managed by bedside drainage and dressings. The addition of an adjuvant jejunostomy even permits home enteral feeding until the leak spontaneously closes. I believe these methods remain the gold standard for reducing anastomotic complications. Decreased Conduit Perfusion Measured by Spectroscopy Is Associated With Anastomotic ComplicationsThe Annals of Thoracic SurgeryVol. 91Issue 2PreviewGastric conduit ischemia during esophagectomy likely contributes to high anastomotic complication rates, yet we lack a reliable method to assess gastric conduit perfusion. We hypothesize that optical fiber spectroscopy (OFS) can reliably assess conduit perfusion and that the degree of intraoperative gastric ischemia is associated with subsequent anastomotic complications. Full-Text PDF