Abstract
BackgroundOur goal was to verify surgical factors that affect duodenogastric reflux (DGR) after esophagectomy through the use of a flow visualization model that would mimic an intrathoracic gastric tube.MethodsTransparent gastric tube models for different routes (retrosternal space [RS] and posterior mediastinum [PM]) were fabricated. Various distal pressures were applied to the experimental model filled with water, and the flow was recorded with a high-speed camera. The volume and maximum height of the refluxate through the pylori of two different sizes (7.5 mm, 15 mm) in two different postures (upright, semi-Fowler) was measured by analyzing the video clips.ResultsFor the large pylorus setting, when the pressures of 20, 30, and 40 mmHg were applied in the upright position, the volumes of the refluxate in the RS/PM tubes were 87.7 ± 1.1/96.4 ± 1.7 mL, 150.8 ± 1.1/158.0 ± 3.2 mL, and 156.8 ± 3.3/198.0 ± 4.7 mL (p < 0.05), and the maximum heights were 101.6 ± 4.8/113.4 ± 2.9 mm, 151.4 ± 2.2/165.4 ± 1.5 mm, and 166.1 ± 1.7/193.7 ± 6.6 mm (p < 0.05). The data for the small pylorus setting or in the semi-Fowler position showed similar tendencies. For any given route, posture or pressure setting, DGR in the large pylorus model was definitively higher than that for small one.ConclusionsThis fluid mechanics study demonstrates posterior mediastinal gastric interposition or pyloric drainage procedure, or both, is associated with high reflux of duodenal contents.
Highlights
Our goal was to verify surgical factors that affect duodenogastric reflux (DGR) after esophagectomy through the use of a flow visualization model that would mimic an intrathoracic gastric tube
For the design of an intrathoracic gastric tube model, we reviewed the postoperative chest CT images of 10 patients with esophageal cancer who underwent esophagectomy with gastric interposition (5 in the retrosternal space (RS) and 5 in the posterior mediastinum (PM)) at Gachon University Gil Hospital
The mean volumes and heights of refluxate when the distal pressures of 20, 30, and 40 mmHg were applied for one second to the model in the upright and semiFowler positions are shown in Tables 1 and 2
Summary
Our goal was to verify surgical factors that affect duodenogastric reflux (DGR) after esophagectomy through the use of a flow visualization model that would mimic an intrathoracic gastric tube. A truncal vagotomy that necessarily accompanies the procedure is considered the main cause of DGR. It impairs the physiological balance between propulsive activity of the antrum and pyloroduodenal. To eliminate this complication, some authors have advocated the omission of a pyloric drainage procedure [7], and the use of an extra-anatomical space as a route of esophageal reconstruction rather than using the posterior mediastinum [3,8]. A reason for these conflicting results is that the clinical data from human subjects is not reproducible due to many other factors that affect DGR and cannot be completely controlled in clinical settings
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