537 Correspondence

Esophageal manometric studies have not proven useful in the diagnosis or treatment of the lower esophageal ring. These studies cannot be relied on to give useful information about anatomical or structural diseases of the esophagus. We do find manometric studies helpful and even essential in the diagnosis of dysphagia in patients in whom the barium esophagram, en- doscopic examination, and cytological studies are normal.

We have not seen a patient with lower esophageal ring who had a hypertensive sphincter. On the contrary, the common findings following rupture of the ring are low esophageal sphincter pressures and, in many patients, mild reflw symp- toms. One must suspect that the elevated sphincter pressures Dr. Silber has found are either artifactual or associated with another esophageal motor disorder.

The “steakhouse syndrome” is not limited to the edentulous but is seen frequently in those who attend dinners where the social stresses are great or alcohol is imbibed freely. These fac- tors may result in poor mastication of meat, which is the type of food incriminated most often in causing acute obstruction. In our experience, obstruction has been caused by chicken or tur- key rather than steak, which may be a reflection of socioeco- nomic status.

In treatment of the lower esophageal ring, gentle dilation should not be used. The gentle stretching of a ring does not relieve dysphagia for any length of time. We believe the treat- ment is to break or fracture (not dilate) the ring with a large dilator in the size range of 40 to 50F in order to obtain a good and prolonged response.

Charles E . Eastridge, M . D .

Chief, Thoracic Surgery Professor, General and Thoracic Surgery Veterans Administration Medical Center 2030 J@erson Ave Memphis, TN 38204

References 1. MacMahon HE, Schatzki R, Gary JE: Pathology of a lower

esophageal ring: report of a case with autopsy observed for nine years. N Engl J Med 2591, 1958

2. Barrett NR Benign stricture in the lower esophagus. J Thorac Cardiovasc Surg 43:703, 1962

Preoperative Spirometry: Let’s Do It! To the Editor:

I read with interest the recent article in The Annals by Keagy and colleagues [l]. In this study, the authors conclude that preoperative spirometric studies (forced expiratory volume [FEV], FEV in 1 second [FEVI], and the ratio of FEV, to forced vital capacity) failed to distinguish patients who would do poorly following pneumonectomy. This impression is given in the Comment section: “Thus, it is difficult to support the use of these tests as a firm basis for making clinical decisions regard- ing operability.” I could more strongly support this conclusion if the following questions were addressed.

1. Were any members of the health care team influenced in any way by the results of these tests, or were they ”blinded to the results? There are at least two studies that document reductions in postoperative morbidity by appropriate preoperative preparation and screening [2, 31. Therefore, any intensification of perioperative therapy could have im- proved the postoperative result.

2. Were any patients excluded from surgical intervention and subsequent analysis because they were considered “physio- logically inoperable?” For example, did patients walk up stairs (41, exercise with a flow-directed catheter (51, or undergo lung scanning [6, 71 or lateral position testing [8]? Or were they simply empirically deemed unable to undergo operation because of age or because they “looked bad?” If patients were denied operation based on results of spirometric tests, the differences between the groups would be blurred.

Unless the methods of ‘%blinding” the care team are specified or the control group is defined, it is hard to exclude these forms of unintentional bias. If any form of perioperative therapy was given to those at highest risk or any patient was excluded as a result of these data, the absence of statistical differences be- tween the groups would not be surprising. In summary, I can support the authors’ conclusion not to make the definitive deci- sion regarding operability on the basis of spirometry alone [9]. I would, however, suggest that preoperative preparation and noninvasive studies may be warranted based on the result of preoperative “screening” spirometry.

Gerald N . Olsen, M . D .

Director, Division of Pulmona y Medicine University of South Carolina School of Medicine Columbia, SC 29208

References 1. Keagy BA, Schorlemmer GR, Murray GF, et al: Correlation

of preoperative function testing with clinical course in pa- tients after pneumonectomy. Ann Thorac Surg 36:253, 1983

2. Stein M, Cassara E L Preoperative pulmonary evaluation and therapy for surgery patients. JAMA 211:787, 1980

3. Gracey DR, Divertie MB, Didier El? Preoperative pulmonary preparation of patients with chronic obstructive pulmonary disease. Chest 76:123, 1979

4. Van Nostrand D, Kjesberg MO, Humphrey EW Preresec- tional evaluation of risk from pneumonectomy. Surg Gy- necol Obstet 127306, 1968

5. Fee HJ, Holmes EC, Gewirtz HS, et al: Role of pulmonary vascular resistance measurements in the preoperative evalu- ation of candidates for pulmonary resection. J Thorac Car- diovasc Surg 75:519, 1978

6. Olsen GN, Block AJ, Tobias JA: Prediction of post- pneumonectomy pulmonary function using quantitative macroaggregate lung scanning. Chest 66:13, 1974

7. Wemly JA, DeMeester TR, Kirchner PT, et al: Clinical value of quantitative ventilation-perfusion lung scans in the surgi- cal management of bronchogenic carcinoma. J Thorac Car- diovasc Surg 80:535, 1980

8. Walkup RH, Vossel LF, Griffin JP, et al: Prediction of postop- erative pulmonary function with the lateral position test. Chest 7724, 1980

9. Olsen GN, Block AJ, Swenson EW. Pulmonary function evaluation of the lung resection candidate: a prospective study. Am Rev Respir Dis 111:379, 1975

Reply To the Editor:

My associates and I are pleased that Dr. Olsen supports our conclusion that a definitive decision regarding the operability of

538 The Annals of Thoracic Surgery Vol 38 No 5 November 1984

pulmonary resection candidates :should not be made solely on the basis of spirometric testing. Clr. Olsen suggests that further preoperative pulmonary evaluation may be necessary based on the results of "screening spironietry." We concur with this opinion, and other testing options are discussed in the text of our paper and cited in the bibliography. Dr. Olsen has amplified this list of references.

In response to the questions Concerning the clinician's preoperative knowledge of the test results, our study was a retrospective one and the operahng surgeon had full knowl- edge of the spirometric data. It is possible that intensification of perioperative therapy was based on a poor test result. Never- theless, it seems clear that poor spirometric test results alone are not a contraindication to pulmonary resection.

Blair A . Keagy, M . D

Division of Cardiothoracic Surgery University of North Carolina Burnett-Womack Clinical Sciences Bldg 2298 Chapel Hill, NC 27514

Aortic Cannulation with Rrtbio Aortic Punch To the Editor:

The article by Garcia-Rinaldi and associates [l] concerning simplified aortic cannulation prompts me to report on a related technique.

Since its introduction, I have used the Rubio aortic punch* [2] in more than 300 patients requiring cannulation of the ascend- ing aorta for cardiopulmonary bypass procedures. In addition to shortening the procedure, use of the aortic punch prevents the well-known problems associated with this type of cannu- lation; I have encountered no complications. It appears that the elimination of surgical forceps, aortic dilators, and knives makes this a very safe and expeditious technique. Moreover, use of double pursestring sutures at the level of the aortic ad- ventitia to achieve hemostasis is an excellent complement to the procedure.

Pedro A. Rubio, M . D .

Chief, Department of Surgery Medical Center Del Or0 Hospital Houston, TX 77054

References 1. Garcia-Rinaldi R, Vaughan GD 111, Revuelta JM, et al:

Simplified aortic cannulation. Ann Thorac Surg 36226, 1983 2. Rubio PA, Farrell EM: Aortic punch: an adjunct for cannula-

tion of the ascending aorta during extracorporeal circulation. Cardiovasc Dis (Bull Tex Heart Inst) 6347, 1979

'Codman & Shurtleff, Inc., Randolph, MA 02368 (Catalog No. 36- 2023).

Upper Extremity Vein Graft To the Editor:

The article by Prieto and colleagues [l] ,points out the difficulties involved in performing coronary artery bypass operations in

patients without a greater saphenous vein. We do not share the authors' enthusiasm for the use of upper extremity vein as a first alternative, and it is unfortunate that better artificial grafts are not available. The internal mammary artery is an ideal graft and should be utilized in these patients. However, when multi- ple grafts are needed, complete revascularization may not be possible without an additional conduit. Surgeons should be aware that most patients who have undergone greater saphe- nous vein stripping still have a lesser saphenous vein in situ. This vein is comparable in quality to the greater saphenous vein and when it is removed from both legs, multiple (five or six) grafts may be performed with ease. Removal of the short saphe- nous vein is simple and does not require placing the patient in the prone position [2]. When the long saphenous vein is not available, our alternative is the use of internal mammary artery combined with lesser saphenous vein bypass.

Tomas A. Salerno, M . D . Larry R. Kaiser, M . D .

Cardiovascular Surgery St. Michael's Hospital 30 Bond St Toronto, Ont, Canada M5B 1W8

References 1. Prieto I, Basile F, Abdulnour E: Upper extremity vein graft

for aortocoronary bypass. Ann Thorac Surg 37218, 1984 2. Salerno TA, Charrette EJF: The short saphenous vein: an

alternative to the long saphenous vein for aortocoronary bypass. Ann Thorac Surg 25:457, 1978

Reply To the Editor:

We agree with most of the points raised by Drs. Salerno and Kaiser.

We have clearly stated that the internal mammary artery and the long saphenous vein, when present and adequate, are es- tablished vessels for autologous grafts. We have always tried to use the short saphenous vein when possible. However, all the patients reported in our article had previous stripping of both saphenous veins. In one instance, we used the short saphenous vein for one of the bypass grafts (Patient 8). When lower limbs veins are not available, the veins of the upper limbs provide valuable alternatives.

Contrary to the understanding of Drs. Salerno and Kaiser, we have not shown undue enthusiasm for the use of upper extrem- ity veins. Moreover, in spite of satisfactory short-term results, we have reservations about the long-term follow-up, which we intend to evaluate. We believe that an improvement might be obtained if one refrains from using the dilated connecting veins of the front of the elbow.

lgnacio Prieto, M . D . Fadi Bade, M . D .

Hatel-Dieu de Montreal 3840 rue St.-Urbain Montreal, PQ, Canada H2W 1T8