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LETTERS TO THE EDITOR
July 23, 1976
Dear Editor: We would like to thank Dr. Munson for his comments concerning our article "Evaluation of Catheter Placement in the Treatment of Venous Air Embolism" (Ann. Surg., 183:58-61, 1976). The first point that warrants emphasis is that our paper addressed itself primarily to treatment of acute air embolism and not with the methodology of early diagnosis. We believe that we said no more than the data allowed. As indicated, our animal data did not seem to support the placing of a Swan-Ganz catheter in the right ventricle or pulmonary artery solely for the treatment of air embolism. In Dr. Munson's article "Early Detection of Venous Air Embolism Using a Swan-Ganz Catheter" (Anesthesiology, 42:223-226, 1975) a rise in pulmonary artery pressure was noted to be an early indicator of venous air embolism. Indeed, our data (unreported) also substantiated this rise in pulmonary artery pressure with acute air embolism. Dr. Munson's report, however, demonstrated no proven superiority in detecting venous air embolism by monitoring pulmonary artery pressure as opposed to the continuous monitoring of end-tidal CO2 concentrations or the monitoring of heart sounds with a transthoracic ultrasonic doppler device. Until such information is forthcoming we do not feel that the placement of a Swan-Ganz catheter is necessarily indicated for diagnostic purposes when less invasive and apparently effective alternative methods of detecting venous air embolism are available. In the interium, it would seem judicious to use those techniques that the anesthesia team is familiar with until firm evidence establishes the superiority of one method over another. James D. Sink, M.D. Paul B. Comer, M.D. Bowman Gray School of Medicine Wake Forest University Winston-Salem, North Carolina
June 11, 1976 Dear Editor:
Dr. Ward 0. Griffen in his paper "Unified Approach to Carcinoma of the Esophagus" (May 1976), has neglected to give proper historical credit to Dr. Henry Heimlich, the American surgeon who courageously persisted over the past twenty years in demonstrating the merits of the reversed gastric tube, while most surgeons were involved with the now outmoded colon transplant. Dr. Griffen, in his paper, is apparently unaware of the
Ann. Surg. * November 1976
fact that Doctors Dan Gavriliu and Henry J. Heimlich independently recommended splenectomy when performing reversed gastric tube operation, the step that made this procedure practical for esophagoplasty. The reversed gastric tube procedure is recommended by Dr. Griffen for all carcinomas of the esophagus. Dr. Heimlich has pointed out repeatedly that carcinoma of the lower third of the esophagus spreads rapidly to the nodes of the celiac axis; therefore, adequate surgical resection requires excision of the proximal stomach, ruling out the reversed gastric tube for this purpose. Boris Schwartz, M.D. 400 Park Avenue Paterson, New Jersey 07504
July 12, 1976 Dear Editor: I did not neglect or intend to neglect the persistent work of my friend, Dr. Henry Heimlich, with regard to the reverse gastric tube. Two of Dr. Heimlich's papers are quoted in my report, but even Dr. Hemilich in his earliest paper credits Dr. Gavriliu with renewing interest in a method of esophageal replacement first described in the early 1900's. I do not know where Dr. Schwartz got the notion that I was "apparently unaware" of the need for splenectomy in the procedure. The description and illustrations of the technique in my article are the same as that employed by Drs. Heimlich and Gavriliu including splenectomy. The major thrust of my paper is the unified approach. A few cases of esophageal carcinoma involving the distal third of the esophagus, even the spread to the celiac nodes, may be cured by a wide esophagogastrectomy. However, most cases where there has been spread to lymph nodes below the diaphragm will not be cured even by eosphagogastrectomy, and the morbidity and mortality associated with that procedure compared to the reverse gastric tube is considerably higher. In addition, it is possible to remove the esophagus and the gastroesophageal junction along with a celiac node dissection and still preserve sufficient blood flow in the left gastroepiploic vessels to permit the construction of a reverse gastric tube. Finally, if the reverse gastric tube technique can be used successfully, it will allow resection of the entire intrathoracic esophagus which may lead to more cures and better palliation. Ward 0. Griffen, Jr., M.D. Professor and Chairman University of Kentucky Lexington, Kentucky 40506
LETTERS TO THE EDITOR
July 23, 1976
Dear Editor: We would like to thank Dr. Munson for his comments concerning our article "Evaluation of Catheter Placement in the Treatment of Venous Air Embolism" (Ann. Surg., 183:58-61, 1976). The first point that warrants emphasis is that our paper addressed itself primarily to treatment of acute air embolism and not with the methodology of early diagnosis. We believe that we said no more than the data allowed. As indicated, our animal data did not seem to support the placing of a Swan-Ganz catheter in the right ventricle or pulmonary artery solely for the treatment of air embolism. In Dr. Munson's article "Early Detection of Venous Air Embolism Using a Swan-Ganz Catheter" (Anesthesiology, 42:223-226, 1975) a rise in pulmonary artery pressure was noted to be an early indicator of venous air embolism. Indeed, our data (unreported) also substantiated this rise in pulmonary artery pressure with acute air embolism. Dr. Munson's report, however, demonstrated no proven superiority in detecting venous air embolism by monitoring pulmonary artery pressure as opposed to the continuous monitoring of end-tidal CO2 concentrations or the monitoring of heart sounds with a transthoracic ultrasonic doppler device. Until such information is forthcoming we do not feel that the placement of a Swan-Ganz catheter is necessarily indicated for diagnostic purposes when less invasive and apparently effective alternative methods of detecting venous air embolism are available. In the interium, it would seem judicious to use those techniques that the anesthesia team is familiar with until firm evidence establishes the superiority of one method over another. James D. Sink, M.D. Paul B. Comer, M.D. Bowman Gray School of Medicine Wake Forest University Winston-Salem, North Carolina
June 11, 1976 Dear Editor:
Dr. Ward 0. Griffen in his paper "Unified Approach to Carcinoma of the Esophagus" (May 1976), has neglected to give proper historical credit to Dr. Henry Heimlich, the American surgeon who courageously persisted over the past twenty years in demonstrating the merits of the reversed gastric tube, while most surgeons were involved with the now outmoded colon transplant. Dr. Griffen, in his paper, is apparently unaware of the
Ann. Surg. * November 1976
fact that Doctors Dan Gavriliu and Henry J. Heimlich independently recommended splenectomy when performing reversed gastric tube operation, the step that made this procedure practical for esophagoplasty. The reversed gastric tube procedure is recommended by Dr. Griffen for all carcinomas of the esophagus. Dr. Heimlich has pointed out repeatedly that carcinoma of the lower third of the esophagus spreads rapidly to the nodes of the celiac axis; therefore, adequate surgical resection requires excision of the proximal stomach, ruling out the reversed gastric tube for this purpose. Boris Schwartz, M.D. 400 Park Avenue Paterson, New Jersey 07504
July 12, 1976 Dear Editor: I did not neglect or intend to neglect the persistent work of my friend, Dr. Henry Heimlich, with regard to the reverse gastric tube. Two of Dr. Heimlich's papers are quoted in my report, but even Dr. Hemilich in his earliest paper credits Dr. Gavriliu with renewing interest in a method of esophageal replacement first described in the early 1900's. I do not know where Dr. Schwartz got the notion that I was "apparently unaware" of the need for splenectomy in the procedure. The description and illustrations of the technique in my article are the same as that employed by Drs. Heimlich and Gavriliu including splenectomy. The major thrust of my paper is the unified approach. A few cases of esophageal carcinoma involving the distal third of the esophagus, even the spread to the celiac nodes, may be cured by a wide esophagogastrectomy. However, most cases where there has been spread to lymph nodes below the diaphragm will not be cured even by eosphagogastrectomy, and the morbidity and mortality associated with that procedure compared to the reverse gastric tube is considerably higher. In addition, it is possible to remove the esophagus and the gastroesophageal junction along with a celiac node dissection and still preserve sufficient blood flow in the left gastroepiploic vessels to permit the construction of a reverse gastric tube. Finally, if the reverse gastric tube technique can be used successfully, it will allow resection of the entire intrathoracic esophagus which may lead to more cures and better palliation. Ward 0. Griffen, Jr., M.D. Professor and Chairman University of Kentucky Lexington, Kentucky 40506
