In Reply:—

We have read with interest the case report by Brodsky et al.  1We believe there are some important issues that are raised by this report.

Brodsky et al.  1suggest that the usual steps recommended for reduction of aspiration risk probably are ineffective. Although the effectiveness of H2-receptor antagonists in reducing acidity in the presence of vagotomy is questionable, prokinetic agents have some theoretic potential benefit; the neutralization of any acid present with sodium citrate also would be beneficial. We also refute the notion that the Sellick maneuver is ineffective. After transhiatal esophagectomy, the cervical esophagogastric anastomosis is located endoscopically 19 or 20 cm from the upper incisors, 4 or 5 cm distal to the upper esophageal sphincter. Correctly applied cricoid pressure should be as effective in preventing passive regurgitation of intrathoracic gastric contents in a patient who underwent transhiatal esophagectomy as it is in any other patient. In our institution, we have significant experience with this procedure, 2and we frequently anesthetize patients for subsequent surgeries; it is standard practice to apply cricoid pressure during induction and intubation. We are unaware of significant cases of pulmonary aspiration in our patients and strongly recommend the use of cricoid pressure when anesthetizing patients who have undergone transhiatal esophagectomy.

We also strongly endorse the use of a jejunostomy tube for the administration of milk and cream in these patients, for the same purpose of identifying the thoracic duct in cases of chyle leak. If the jejunostomy already has been removed or was not placed at the original operation, a Dobhoff feeding tube placed distal to the ligament of Treitz permits safe delivery of this mixture into the gut.

Brodsky JB, Brock-Utne AJ, Levi DC, Ikonomidis JS, Whyte RI: Pulmonary aspiration of a milk/cream mixture. A nesthesiology 1999; 91: 1533–4
Orringer MB, Marshall B, Iannettoni MD: Transhiatal esophagectomy: Clinical experience and refinements. Ann Surg 1999; 230: 392–400