Gastric Graft Research Articles

New linear stapled semimechanical esophagogastric anastomosis with invagination

Objective. Development and implementation esophagogastric linear stapled semimechanical anastomosis with invagination. Material and methods. Seromuscular stitches are applied over 4 cm on both sides to the lateral surfaces of the esophagus posterior wall and gastric graft posterior wall, towards their edges. The posterior wall of the anastomosis is sutured and cutted with a linear stapler on 30–40 mm deep. The anterior wall sutured with a linear stapler. The next layer of sutures on the anastomosis anterior wall invaginates the anastomos and the esophageal stump into the gastric graft. Results. There was no early postoperative mortality. Average I. Lewis minimally invasive esophagectomy time was 353 minutes (245–470 minutes). The average volume of blood loss was 114 mL (50–200 mL). No patient faced an anastomotic leak. Anastomotic stricture occurred in 5 patients (19.2%) during 21 days to 6 months of follow-up. There were no anastomosis-related complications above Clavien-Dindo grade II. Conclusions. Linear stapled semimechanical anastomosis with invagination has proven both clinical and technical advantages of its use.

Mitochondrial dysfunction induced by HIF-1α under hypoxia contributes to the development of gastric mucosal lesions.

Hypoxia is an important characteristic of gastric mucosal diseases, and hypoxia-inducible factor-1α (HIF-1α) contributes to microenvironment disturbance and metabolic spectrum abnormalities. However, the underlying mechanism of HIF-1α and its association with mitochondrial dysfunction in gastric mucosal lesions under hypoxia have not been fully clarified. To evaluate the effects of hypoxia-induced HIF-1α on the development of gastric mucosal lesions. Portal hypertensive gastropathy (PHG) and gastric cancer (GC) were selected as representative diseases of benign and malignant gastric lesions, respectively. Gastric tissues from patients diagnosed with the above diseases were collected. Portal hypertension (PHT)-induced mouse models in METTL3 mutant or NLRP3-deficient littermates were established, and nude mouse gastric graft tumour models with relevant inhibitors were generated. The mechanisms underlying hypoxic condition, mitochondrial dysfunction and metabolic alterations in gastric mucosal lesions were further analysed. HIF-1α, which can mediate mitochondrial dysfunction via upregulation of METTL3/IGF2BP3-dependent dynamin-related protein 1 (Drp1) N6-methyladenosine modification to increase mitochondrial reactive oxygen species (mtROS) production, was elevated under hypoxic conditions in human and mouse portal hypertensive gastric mucosa and GC tissues. While blocking HIF-1α with PX-478, inhibiting Drp1-dependent mitochondrial fission via mitochondrial division inhibitor 1 (Mdivi-1) treatment or METTL3 mutation alleviated this process. Furthermore, HIF-1α influenced energy metabolism by enhancing glycolysis via lactate dehydrogenase A. In addition, HIF-1α-induced Drp1-dependent mitochondrial fission also enhanced glycolysis. Drp1-dependent mitochondrial fission and enhanced glycolysis were associated with alterations in antioxidant enzyme activity and dysfunction of the mitochondrial electron transport chain, resulting in massive mtROS production, which was needed for activation of NLRP3 inflammasome to aggravate the development of the PHG and GC. Under hypoxic conditions, HIF-1α enhances mitochondrial dysfunction via Drp1-dependent mitochondrial fission and influences the metabolic profile by altering glycolysis to increase mtROS production, which can trigger NLRP3 inflammasome activation and mucosal microenvironment alterations to contribute to the development of benign and malignant gastric mucosal lesions.

Comparative evaluation of different types of gastric conduits used for single-stage reconstruction during oesophageal cancer esophagectomy. Review

In the treatment of local and local‑regional oesophageal cancer, esophagectomy takes centre stage. It is a complex procedure with a high rate of postoperative complications. There are different methods for oesophageal reconstruction, including colon interposition, supercharged jejunal interposition, and gastric pull‑up. Each has both advantages and disadvantages. However, a gastric graft is the preferred option due to the less traumatic nature of the operation. Currently, there are different methods for forming a gastric graft. Gastric conduits are classified based on their shape and can be categorised as whole‑stomach, sub‑total stomach, or gastric tube. Previous research on the functional characteristics of gastric conduits revealed that the most effective solution is a typical gastric tube. Due to its width (3—6 cm), the gastric tube limits its impact on lung movement within the pleural cavity, hence decreasing the incidence of postoperative respiratory complications (e.g., pneumonia). Pulmonary complications and anastomotic leaks are the main contributing causes of postoperative morbidity and mortality after esophagectomy. Other complications include technical and functional issues, as well as delayed problems such as anastomotic strictures and disease recurrence. However, the rate of complications remains between 20 and 80%, prompting oncologic surgeons to develop new methods for gastric conduit formation. Over the past 5 years, innovative methods using a special‑shaped gastric tube have been suggested. They appear to decrease the incidence of postoperative complications and enhance nutritional outcomes. This study aimed to evaluate the advantages of using special‑shaped gastric tubes in clinical practice as opposed to whole‑stomach and typical gastric tubes.

Different gastric tubes in esophageal reconstruction during esophagectomy.

Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.

PECULIARITIES OF POSTOPERATIVE PERIOD OF PATIENTS WITH ESOPHAGEAL CANCER AND GASTROESOPHAGEAL CANCER

Abstract. Introduction. To date, complete cure from esophageal cancer/MS/and gastroesophageal cancer/GER/can only be achieved surgically. At the same time, the five-year survival rate of patients is from 25 to 35 % according to various authors. At the same time, postoperative mortality in MS and GER reaches 15%, and only in leading clinics it is 3–9 %. In the treatment of cancer of these localizations, there are many controversial issues, namely the issue of optimal surgical access in cancer of various anatomical departments of the esophagus and GER, the volume of lymphodissection, the reconstructive stage of surgery, the relation to splenectomy. There is insufficient information on the prevention and treatment of postoperative complications.
 Purpose. Establish the nature of postoperative complications in patients with MS and GER and study the possibilities of preventing their development.
 Materials and methods. The results of surgical treatment of 219 pa-tients with esophageal cancer/MS/and gastroesophageal cancer/ GER/are presented. The patient underwent surgical interventions according to the method of Lewis/98/and Osava-Garlock/121/. The formation of esophageal-gastric anastomosis was carried out manually without the use of cross-linking devices. Preferred plastic submerged esophageal-gastric anastomosis, which has high reliability and good functional properties. Postoperative complications and factors that cause them were analyzed. The clinical case of diagnosis and treatment of gastric graft rotation is presented.
 Research results. Complications in the postoperative period occurred in 34.95 % of patients. The leading place was occupied by somatic complications: cardiovascular 17.1% and pulmonary 12.0 %. Complications from esophageal ventricular anastomosis occurred in only 4 (1.8%) patients, and in no case this led to the death of the patient. Intrapleural bleeding from the chest wall (1.4 %) and gastric cookies (1.0%) were very rare. There are also complications in the form of gastric graft rotation and complete obstruction. This complication was eliminated by the imposition of gastroenteroanastomosis on the abdominal gland of the stomach in laparotomy.
 Deaths were caused in 3 (1.4 %) patients with cardiovascular insufficiency and in 1 (0.5 %) patient with TELA.
 Conclusions. Prominent in the structure of postoperative complications are therapeutic: cardiovascular and pulmonary, they account for more than 80% of all complications. The most common cardiovascular complication is a heart rhythm disorder.
 The method of formation of esophageal anastomosis is a separate independent side of the problem. The search for the optimal method continues. However, in our opinion, the result depends not so on the method used, but how this method corresponds to the principles of optimal healing of anastomosis and the correctness of its technical performance.
 For the prevention of transplant rotation during surgery, control of its location, both from the chest and abdominal cavity, is necessary, so the latter is sutured only after the formation of esophageal-gastric anastomosis.
 In gastric graft rotation, urgent surgery is shown to perform drainage surgery.

Left Ventricular Wall Reconstruction with Autologous Vascularized Tunica Muscularis of Stomach in a Porcine Pilot Model

Introduction: Surgical replacement of dysfunctional cardiac muscle with regenerative tissue is an important option to combat heart failure. But, current available myocardial prostheses like a Dacron or a pericardium patch neither have a regenerative capacity nor do they actively contribute to the heart’s pump function. This study aimed to show the feasibility of utilizing a vascularized stomach patch for transmural left ventricular wall reconstruction. Methods: A left ventricular transmural myocardial defect was reconstructed by performing transdiaphragmatic autologous transplantation of a vascularized stomach segment in six Lewe minipigs. Three further animals received a conventional Dacron patch as a control treatment. The first 3 animals were followed up for 3 months until planned euthanasia, whereas the observation period for the remaining 3 animals was scheduled 6 months following surgery. Functional assessment of the grafts was carried out via cardiac magnetic resonance tomography and angiography. Physiological remodeling was evaluated histologically and immunohistochemically after heart explantation. Results: Five out of six test animals and all control animals survived the complex surgery and completed the follow-up without clinical complications. One animal died intraoperatively due to excessive bleeding. No animal experienced rupture of the stomach graft. Functional integration of the heterotopically transplanted stomach into the surrounding myocardium was observed. Angiography showed development of connections between the gastric graft vasculature and the coronary system of the host cardiac tissue. Conclusions: The clinical results and the observed physiological integration of gastric grafts into the cardiac structure demonstrate the feasibility of vascularized stomach tissue as myocardial prosthesis. The physiological remodeling indicates a regenerative potential of the graft. Above all, the connection of the gastric vessels with the coronary system constitutes a rationale for the use of vascularized and, therefore, viable stomach tissue for versatile tissue engineering applications.

The Features of Stomach Vascularisation Pattern and Their Impact on Oesophageal Reconstruction with a Gastric Pull-up.

Regardless of the reconstruction surgery used, the fundamental concepts of visceral reconstruction are based on the vascular support needed for the substituting graft. The vascular factor is the main element of any reconstruction technique, as an underlying condition for the visceral material stretch and, along with other factor, for the suture safety. In the case of the stomach, a consistent vascular flow and the minimal vascular anatomy variations are the first theoretical argument. A second argument is based on the intraparietal vascular network features allowing for supplementing visceral perfusion as the blood flow is stopped in one or more pediculi. Graft hypoperfusion is, however, a potential cause of failure, and the most frequently invoked complication is, therefore, a high risk of anastomosis fistulae. A series of modern techniques - arteriography data for the pre-operative vascular reconstruction or Doppler laser fluorometry intraoperative assessments, graft oximetry, laser speckle (spot) scan or the use of indocyanine green staining (ICG) - represent methods of early determination of the gastric graft perfusion/microperfusion quality used in reducing such risks. The doubts regarding the gastric perfusion mandate the use of vascular augmentation techniques. If such techniques are not used, the final outcome is uncertain and difficult to correct.

Metachronous carcinoma of the gastric tube following tumour-associated oesophagectomy.

The prognosis of oesophageal carcinoma has improved during the last years. Thereby, the increasing survival has led to increasing occurrence of secondary gastric tube carcinoma (gastric conduit cancer, GTC) following oesophageal tumour resection. A literature review (EMBASE, PubMed), spanning the years 2000 to 2020, identified 342 patients worldwide with a GTC following tumour-related oesophagectomy, of which 306 patients could be included for further analysis. The median age of 306 patients with GTC was 66.4 (39-80) years. 91.2% of patients (n = 279) were male. The median interval between oesophagectomy and GTC was 60.3 (4-236) months. 73.8% of patients (n = 226) were diagnosed as early cancer (EGC, T1) and 26.2% as advanced carcinoma (AGC, > T2; n = 80). Primary oesophagectomy was performed in 97.4% of patients (N = 298) for squamous cell carcinoma. AEG I carcinoma was present in only 5 patients (1.6%). In contrast, 99% (n = 303) of the GTC were found to be adenocarcinomas. One hundred eighty patients (58.8%) could be treated by endoscopic resection (ER). R0 resection was achieved in 82.8% (n = 149). The complication rate was 13.3% (n = 24) and the 30-day mortality 1.1% (n = 2) for ER. Eighty-three patients (27.1%) were treated surgically. These included 13 wedge resections, 25 partial resections and 45 total gastric graft resections with predominantly colon interposition. The R0 rate was 98.8% (n = 82). The postoperative morbidity was 24.1% (n = 20); the 90-day mortality was 6% (n = 5). In 43 patients (14%), palliative chemotherapy or radiotherapy or best supportive care took place. GTC diagnosed early in the EGC stage can be safely managed with ER. In cases of advanced GTC, surgical resection can be a potentially curative approach. Survival times of up to 120months have been described after intervention for GTC.

Evaluation of the lower histologic threshold for gastric graft versus host disease.

Data regarding the lower diagnostic threshold for gastric graft-versus-host disease is lacking. The aim of this study was to review a cohort of gastric biopsies taken to evaluate for graft-versus-host disease, and to correlate histologic findings with clinical and endoscopic evidence of graft-versus-host disease as well as biopsy findings from other locations to define a lower diagnostic threshold for gastric graft-versus-host disease. Gastric biopsies were evaluated for the maximum number of apoptotic bodies per 10 contiguous gastric pits, presence of ≥1 apoptotic body per biopsy (NIH criteria), and presence of gastric pit dropout and/or ulceration. To evaluate histologic specificity, sixty gastric biopsies from non-stem cell transplant patients were selected as a control group. Clinical information was collected from chart review. The study group consisted of 65 gastric biopsies from 52 stem cell transplant patients. The mean apoptotic count per 10 contiguous gastric pits for stem cell transplant biopsies was 1.8 (range 0-8) and for control cases 1.0 (range 0-5). Nineteen stem cell transplant biopsies (29%) had ≥1 apoptotic body per biopsy and only a single case had >6 apoptotic bodies per 10 contiguous gastric pits. When the NIH guidelines were combined with presence of at least two apoptotic bodies per 10 contiguous gastric pits, this cutoff point was significantly associated with treatment for graft-versus-host disease (OR = 9.4, 95% CI = 1.7-176.7, p = 0.04) and evidence of extraintestinal graft-versus-host disease (OR = 3.2, 95% CI = 1.1-10.7, p = 0.04). The diagnostic specificity for our proposed cutoff value is 94%. We present criteria for the lower diagnostic threshold of gastric graft-versus-host disease, which uses a lower apoptotic cutoff value than has been utilized in colonic biopsies. Although sensitivity remains a challenge for gastric graft-versus-host disease biopsies, this newly proposed cutoff provides higher specificity than NIH guidelines alone and better correlates with clinical evidence of graft-versus-host disease.

P5 FEASIBILITY AND EFFICACY OF INDOCYANINE GREEN ANGIOGRAPHY DURING ESOPHAGECTOMY: A SYSTEMATIC REVIEW

Abstract Aim The aim of this review was to evaluate feasibility and effectiveness of Indocyanine green fluorescence angiography (ICGA) as an assessment tool for gastric tube (GT) perfusion during the construction of the esophago-gastric anastomosis, and as a predictor of anastomotic leakage (AL). Moreover, attention was given to attempts made to quantify this method in esophageal surgery. Background & Methods After an esophagectomy, a GT is most commonly used to restore continuity of the upper gastrointestinal tract. Esophago-gastric anastomoses are known for their complications such as AL, associated with high morbidity and mortality. Graft perfusion is an important predictor for anastomotic integrity. Tissue perfusion assessment is currently based on subjective parameters as tissue color and vessel pulsations. Near infrared fluorescent (NIRF) imaging is an emerging medical imaging modality, requiring penetrating NIR light that excites a NIRF agent within the tissue, generating fluorescence that can then be captured by adapted cameras. Indocyanine green Angiography (ICGA) is such a NIRF imaging technique which can be used as a method to visualize anastomotic perfusion. For this review, 2 reviewers independently searched Pubmed and Embase for studies evaluating intraoperative ICGA perfusion assessment of the GT. Feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications were documented and further analyzed. Results Nineteen studies were included for qualitative analyses. All described ICGA as a safe and easy method for gastric graft perfusion assessment. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (p<.001). AL in the well-perfused group was 6.3% vs. 20.5% in the control group without ICGA (p< .001). The group with an altered surgical plan based on the ICG image had similar AL rates as the well perfused group (6.5% vs. 6.3%) and significantly less than the poorly perfused group (47.8%) (p<.001), suggesting that the technique is able to identify and alter a potential bad outcome. Conclusion the present review suggest that ICGA is a safe and easy method for GT perfusion assessment. Differences in AL rate between the well perfused and poor perfused anastomotic sites suggest that a good fluorescent signal is a predictor of good outcome.

Near-infrared fluorescence guided esophageal reconstructive surgery: A systematic review.

BACKGROUNDAfter an esophagectomy, the stomach is most commonly used to restore continuity of the upper gastrointestinal tract. These esophago-gastric anastomoses are prone to serious complications such as leakage associated with high morbidity and mortality. Graft perfusion is considered to be an important predictor for anastomotic integrity. Based on the current literature we believe Indocyanine green fluorescence angiography (ICGA) is an easy assessment tool for gastric tube (GT) perfusion, and it might predict anastomotic leakage (AL).AIMTo evaluate feasibility and effectiveness of ICGA in GT perfusion assessment and as a predictor of AL.METHODSThis study was designed according to the PRISMA guidelines and registered in the PROSPERO database. PubMed and EMBASE were independently searched by 2 reviewers for studies presenting data on intraoperative ICGA GT perfusion assessment during esophago-gastric reconstruction after esophagectomy. Relevant outcomes such as feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications, were collected by 2 independent researchers. The quality of the included articles was assessed based on the Methodological Index for Non-Randomized Studies. The 19 included studies presented data on 1192 esophagectomy patients, in 758 patients ICGA was used perioperative to guide esophageal reconstruction.RESULTSThe 19 included studies for qualitative analyses all described ICGA as a safe and easy method to evaluate gastric graft perfusion. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (P < 0.001). When poorly perfused cases are excluded from the analyses, the difference in AL was even larger (AL well-perfused group 6.3% vs control group 20.5%, P < 0.001). The AL rate in the group with an altered surgical plan based on the ICG image was 6.5%, similar to the well perfused group (6.3%) and significantly less than the poorly perfused group (47.8%) (P < 0.001), suggesting that the technique is able to identify and alter a potential bad outcome.CONCLUSIONICGA is a safe, feasible and promising method for perfusion assessment. The lower AL rate in the well perfused group suggest that a good fluorescent signal predicts a good outcome.

Multiple primary cancers in patients treated for squamous cell carcinoma of the esophagus.

Treatment of squamous cell carcinoma is associated with an increased risk of other primary malignancies, mainly within the head and neck, as well as in the oesophageal gastric graft. More frequent recognition of multiple primary cancers associated with esophageal cancer, both synchronous and metachronous, is associated with longer follow-up after radical cancer treatment for esophageal cancer and high quality diagnostic procedures, both before and after surgery. The paper reviews the available literature and describes the molecular basis of the formation of multiple primary tumors associated with squamous cell carcinoma of the esophagus.

Esophageal Reconstruction with the Stomach, a Functional Dilemma?

Background: A few decades ago, esophageal substitution was mainly dedicated particularly in postcaustic esophageal stenosis; currently, the reconstruction has expanded its palette of indications to other areas of benign esophageal pathology (severe motor disorders, esophageal achalasia with multiple relapses, peptic stenosis, etc.) but has also become a quasi-obligatory final time in the esophagectomy for cancer whenever it is possible. The techniques of esophageal reconstruction using the stomach, regardless of the indication and the chosen technical option, remain a valuable and effective method. A number of striking arguments advocate for one or another type of gastric graft: anatomic factors more than convenient (vascularization, sufficient length, a wall structure favorable for suture, etc.) and a sustainable surgical intervention (length, approach, complexity of the surgical steps digestive disorders after surgery, post-therapeutic functionality, etc.). Choosing a technique or another, beyond pathological arguments, should take into account remote functionality, with a clear impact on metabolic status and quality of life. So, according to this criterion, can we functionally justify a type or another of gastric restoration? Finally, the proof of an adequate solution is relatively easy to appreciate: has swallowing been restored and if so, the result has been maintained over time? For oncological cases, the assessment should also take into account the chronological criterion of the postoperative survival rate. Methods: The statistically rated lot ranged from 1981 to 2016 and included 268 patients with surgical interventions for esophageal stenosis, distributed according to etiopathogenesis and indication in 201 reconstructions for post-caustic stenosis, and 67 for post-esophagectomy replacement for neoplasm. The techniques used for remote functional evaluation included: barium swallow, endoscopy + biopsy, and in cases with obvious changes pH measurement/24 h and manometry and, only in exceptional cases, scintigraphy with marked foods. Results: two types of problems have been identified: a particular type of neuro-motor dysfunction of the esophageal substitute in 6 patients (1 patient with Gavriliu reconstruction and 5 with Nakayama reconstruction, using the whole stomach), with difficulty, delayed gastric graft evacuation, with major stasis and abdominal discomfort vomiting, inability to eat, aspiration phenomena) respectively a reflux pathology - 8 patients, being proved by a specific simptomatology, barium lunch, endoscopic examination and pH-metric examination. Reflux was alkaline in 7 patients, all with pyloroplasty, 5 with whole stomach and 2 with Akiyama procedure; in 1 case with Gavriliu procedure the reflux was acid. Conclusions: Stomach is a good option in esophageal substitution. Concerning the remote results, a good functionality is found with a reasonable metabolic status. The two phenomena on which the function of the graft depends - secretory activity and motor activity - seem to be restored in time but these does not occur concurrently, the recovery of the secretory function being much faster.

Late Complications of Colon Interposition for Esophageal Reconstruction

Introduction: Successful restoration of digestive continuity following esophagectomy is a challenge. Gastric graft remains is the first option to reconstruct diseased esophagus. However, colon graft is preferable in some instances. Colon interposition is a complex and more demanding surgical procedure. The long-term functional results of colon interposition were satisfactory and can be subsequently affected by late complications. We reported in this retrospective study, the late complications occurred after left colon interposition performed for esophageal caustic stricture from 2000 to 2016. Patients and Methods: Sixteen of 107 patients who received left colon interposition for esophageal caustic stricture developed a late complication. There were 15 women and one man with median age of 20 years. Three patients had a previous cervical leak and thoracic inlet was widened in 2 cases. Results: The late post-operative morbidity rate was 14.9%. Cervical anastomotic stricture occurred in 8 patients. Dilations were successful in 6 patients and surgical revision was required in 2 patients. Symptomatic mild gastrocolic reflux occurred in 5 patients and Symptoms improvement had been obtained after medical treatment and lifestyle modification. Two patients developed graft redundancy and surgery was required after failure of life-style modification measures. It consisted of resecting the redundant colon and performing an end-to-end anastomosis. Conclusion: Late complication after colon interposition can greatly affect swallowing function and quality of life. Surgery is required in some conditions to improve symptoms and life-quality. Identification of predisposing factors and improvement in technique remain the best way to reduce the risk of late complications.

ASSESSMENT OF THE RESULTS OF ESOPHAGOGASTROPLASTY OF SCARRY STRICTURE OF THE ESOPHAGUS AND ESOPHAGEAL ACHALASIA

Department of hospital and pediatric surgery, Novosibirsk State Medical University OBJECTIVE. The authors made a complex assessment of functioning of the artificial esophagus, which was formed from the stomach. The pathological study of biopsy material of mucous coat of the stomach was carried out at different terms after surgery. MATERIALS AND METHODS. The research analyzed the results of esophagogastroplasty in cases of scarry strictures of the stomach after burns and esophageal achalasia in 101 patients. All the patients underwent extirpation of the esophagus with the gastric tube plasty. RESULTS. There weren’t noted any complications with gastric graft functioning. These data were confirmed by X-ray and endoscopy. The structural reorganization of the mucous coat with signs of atrophy was revealed according to the data of pathologic research. CONCLUSIONS. The authors indicated the necessity of the dynamic follow-up of the patients after esophagoplasty.

Transhiatal esophagectomy for cardia and esophagus cancer

To present the result of transhiatal esophagectomies with simultaneous repair. The study included 67 procedures. In 35 cases surgery was carried out for adenocarcinoma of distal esophagus or cardia with high transition to esophagus, in 32 cases - for epidermal carcinoma of the esophagus. Gastric graft and left half of the colon were used in 60 and 7 cases respectively for simultaneous repair. 29 patients underwent transhiatal instrumental esophagectomy using author's original technique.

What is the outcome of paediatric gastrocystoplasty when the patients reach adulthood?

To document the long-term outcomes of paediatric augmentation gastrocystoplasty (AGC) in terms of preservation of renal function and maintenance of dryness, and to analyse the rate of complications. The medical records of children who had undergone AGC between 1992 and 2000 (minimum time interval of 15 years) were reviewed retrospectively. The following data were collected: age at surgery, the cause of bladder dysfunction, functioning of the AGC, any complications, and the long-term outcome of the patients. All of the patients were re-contacted by telephone. A total of 11 AGCs were carried out between 1992 and 2000, at a median (range) age of 11 (6.5-14) years. The diagnosis of patients undergoing AGC included myelomeningocele (four), bladder exstrophy (four), posterior urethral valves (one), irradiated bladder (one), and Prune Belly syndrome (one). The median [interquartile range (IQR)] follow-up was 17 (15-19.5) years. Renal function was preserved or improved in seven of the 11 patients and nine patients were dry after AGC. Seven of the 11 patients reported symptoms linked to haematuria-dysuria syndrome, which was resistant to treatment in one case and requiring excision of the gastric patch. Three of the 11 patients developed a tumour on the gastric graft after a median (range) delay of 20 (11-22) years after the initial procedure. All had gastric adenocarcinoma of which two were metastatic at the time of diagnosis requiring pelvectomy with pelvic lymph node dissection and adjuvant chemotherapy. Seven of the 11 patients underwent excision of the gastric patch after a median (IQR) time of 11 (8.5-20.5) years. Our long-term data confirmed that most patients undergoing AGC had preservation of their renal function and were continent. However, long-term, AGC was associated with a significant risk of malignant transformation and a high rate of surgical re-intervention involving removal of the gastric patch. These results question the use of this technique for bladder augmentation, irrespective of the indication. We highlight the importance of strict endoscopic follow-up of all patients already having undergone an AGC and the need to inform and educated patients about tumour-related symptoms.

High Intrathoracic Anastomosis with Thoracoscopy Is Safe and Feasible for Treatment of Esophageal Squamous Cell Carcinoma.

BackgroundMinimally invasive esophagectomy (MIE) has the potential to reduce the morbidity and mortality of esophageal cancer surgery. Esophageal squamous cell carcinoma (ESCC) has a high incidence of earlier lymphatic spread and is usually located more proximal to the incisor than esophageal adenocarcinoma; consequently, the anastomosis should be made more proximal in the thorax or in the neck. We adopted the proximal intrathoracic anastomotic technique using thoracoscopy for mid-to-lower ESCC.MethodsFrom October 2010 to August 2014, fifty-eight consecutive patients underwent MIE for ESCC. After laparoscopic gastric tubing, thoracoscopic esophageal resection and reconstruction were performed using a 28-mm circular stapler following radical mediastinal lymph node dissection. We tried to make an anastomosis at the apex of the chest. Postoperative outcomes, including overall survival and recurrence, were assessed.ResultsThe mean patient age was 64.3±9 years. The mean operative time was 371.8±51.6 minutes, and the duration of the thorax procedure was 254.8±38.3 minutes. The mean number of lymph nodes dissected was 31±11.7. The mean intensive care unit (ICU) stay and hospital stay were 3.5±8.2 hours and 13.6±7.4 days, respectively. The level of anastomosis was 22.3±1.8cm from the incisor. One patient died of uncontrolled sepsis due to necrosis of the gastric graft. Two patients developed small contained leakage. Nine patients exhibited distant metastasis during the follow-up period.ConclusionThoracoscopic intrathoracic anastomosis at the proximal esophagus is feasible and safe.

Endoscopic assessment 1 day after esophagectomy for predicting cervical esophagogastric anastomosis-relating complications.

There are no useful methods for predicting anastomosis-relating complications after esophagectomy; however, anastomotic leakage remains one of the most serious postoperative complications. We retrospectively investigated the appropriateness of endoscopic examinations on postoperative day 1 (POD 1) for assessing esophageal reconstruction by analyzing the endoscopic findings 1 day after the operation and evaluating the healing process at the site of anastomosis in patients treated with esophageal reconstruction. Between 2010 and 2013, we performed esophageal reconstructive surgery using a retrosternal gastric graft and cervical anastomosis and conducted endoscopic examinations to assess the esophagogastric anastomosis on POD 1 in 153 patients. On endoscopy performed on POD 1, we identified mucosal color change (MCC) in the proximal gastric graft as an important finding that may be indicative of local circulatory failure in gastric grafts. One week after the operation, endoscopic examinations subsequently showed significant mucosal defects around the site of anastomosis that were expected to result in anastomotic leakage as a marker of poor healing of anastomosis as well as leakage. We identified the findings of MCC in 36 patients evaluated with endoscopic examinations performed on POD 1. Furthermore, the endoscopic examinations performed 1 week after the operation revealed poor healing of the anastomosis site in 23 patients, including one patient with major anastomotic leakage. Therefore, poor healing of the anastomosis site more frequently occurred in 20 of the 36 patients (55.6%) who exhibited MCC on the endoscopic examinations performed on POD 1 than in three of the 117 patients (2.6%) who had normal endoscopic findings on POD 1 (p < 0.001). Early endoscopy performed on POD 1 helps to predict the development of poor healing of esophagogastric anastomosis around 1 week after the operation by identifying the findings of MCC in the proximal gastric graft.

Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy

The aim of the study was to evaluate laser-assisted fluorescent-dye angiography (LAA) to assess perfusion in the gastric graft and to correlate perfusion with subsequent anastomotic leak. Anastomotic leaks are a major source of morbidity after esophagectomy with gastric pull-up (GPU). In large part, they occur as a consequence of poor perfusion in the gastric graft. Real-time intraoperative perfusion was assessed using LAA before bringing the graft up through the mediastinum. When there was a transition from rapid and bright to slow and less robust perfusion, this site was marked with a suture. The location of the anastomosis relative to the suture was noted and the outcome of the anastomosis ascertained by retrospective record review. Intraoperative LAA was used to assess graft perfusion in 150 consecutive patients undergoing esophagectomy with planned GPU reconstruction. An esophagogastric anastomosis was performed in 144 patients. A leak was found in 24 patients (16.7%) and were significantly less likely when the anastomosis was placed in an area of good perfusion compared with when the anastomosis was placed in an area of less robust perfusion by LAA (2% vs 45%, P < 0.0001). By multivariate analysis perfusion at the site of the anastomosis was the only significant factor associated with a leak. Intraoperative real-time assessment of perfusion with LAA correlated with the likelihood of an anastomotic leak and confirmed the critical relationship between good perfusion and anastomotic healing. The use of LAA may contribute to reduced anastomotic morbidity.