Gastric Reconstruction Research Articles

Pancreatoduodenectomy: Brazilian practice patterns

Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. The aim of this study is to understand the Brazilian practice patterns for pancreatoduodenectomy. Methods: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Current Status of Voice Restoration Following Total Laryngopharyngoesophagectomy: A Case Report

Hypopharyngeal carcinoma is one of the common head and neck cancers and also more common in men in India. Understanding of the role of the speech-language pathologist (SLP) in the area of assessment and management of this condition is limited. This is a case report of an adult male with recurrent squamous cell carcinoma of hypopharynx, spread to larynx and esophagus. Following total laryngopharyngoesophagectomy (TLPE) with gastric transposition, the patient was aphonic. This case report focuses on the voice restoration options available, that SLP needs to be aware right during pre-operative counselling and his/her role in rehabilitating TLPE patient with gastric transposition reconstruction.

Extent of Gastrectomy and Lymphadenectomy for Gastric Adenocarcinoma

Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This review outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed. This review contains 4 figures, 7 tables, and 50 references. Key words: gastrectomy, gastric cancer, lymphadenectomy, lymph node, lymph node staging, stomach

Extent of Gastrectomy and Lymphadenectomy for Gastric Adenocarcinoma

Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This review outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed. This review contains 4 figures, 7 tables, and 50 references. Key words: gastrectomy, gastric cancer, lymphadenectomy, lymph node, lymph node staging, stomach

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS.

ABSTRACT Background:Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim:To understand the Brazilian practice patterns for pancreatoduodenectomy. Method:A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Application of pancreatic and gastric binding reconstruction in pancreaticoduodenectomy

目的 探讨捆绑式胰胃吻合术（BPG）在胰十二指肠切除术（PD）中的应用价值。 方法 分析11例施行胰十二指肠切除并行胰腺残端与胃捆绑式重建患者（BPG组）临床资料，并与13例同期同龄健康体检者（健康对照组）比较。观察BPG术后患者各项指标变化。采用健康调查简表SF-36量表，对两组进行健康相关生命质量（HRQOL）调查。 结果 BPG组患者术后出现胰腺残端出血1例，经保守治疗后痊愈；术后无胰瘘、胆瘘、胃排空延迟等并发症的发生，术后患者腹腔引流液（χ2=12.416，P=0.000）及腹腔引流液淀粉酶含量逐步降低（χ2=30.745，P=0.000），胃肠减压量逐渐降低（χ2=59.298，P=0.000），胃肠功能恢复较好。患者均痊愈出院。SF-36量表调查结果显示，BPG组患者术后6、12个月生理职能评分分别为（48.8±10.6）、（50.1±9.5）分，低于健康对照组[（79.8±8.6）分]（t=8.171、P=0.000，t=8.350、P=0.000）；术后情感职能评分分别为（63.6±14.3）、（50.2±12.0）分，均低于健康对照组[（82.8±12.4）分]，差异有统计学意义（t=3.662、P=0.001，t=6.806、P=0.000）。而其他维度评分与健康人群比较，差异无统计学意义（均P>0.05），表明患者BPG术后生命质量良好。 结论 在PD中BPG有其自身独特优点，合理应用BPG有可能降低患者术后胰瘘的发生，且患者远期生命质量较好。

One-stage conversion of Roux-en-Y gastric bypass to a modified biliopancreatic diversion with duodenal switch using a hybrid sleeve concept

BackgroundInsufficient weight loss (percentage of excess weight loss [%EWL]<50%) is observed in approximately 20% of patients after Roux-en-Y gastric bypass (RYGB). Surgical revision can be performed by various procedures including malabsorptive techniques. Conversion to a biliopancreatic diversion with duodenal switch (BPD/DS) remains a complex technique which cannot always be performed as a one-stage procedure. ObjectivesThis study evaluates the conversion of RYGB to BPD/DS using a novel gastric reconstruction technique based on a “hybrid sleeve” using the existing gastrojejunal anastomosis of the RYGB. SettingAll the procedures were performed at a private hospital. MethodsThe consecutive patients who were eligible for conversion since 2010 were reviewed; eligibility included %EWL≤50% and normal gastric pouch. The gastrojejunal anastomosis of the RYGB was untouched and the gastric fundus was resected. The gastric continuity was restored by an anastomosis between a short segment of the alimentary limb and the gastric antrum. A standard BPD/DS was then performed without restoration of the jejunal continuity. ResultsFourteen patients were converted to BPD/DS for a mean body mass index (BMI) of 44.3±6.0 kg/m2, a mean %EWL of 33.4%, and a percentage of total weight loss (%TWL) of 15.3±11.7%. The BMI before RYGB was 54.4±13.1 kg/m2, with half of the patients being super-obese. All but 3 conversions were completed as a single stage and laparoscopically in a mean of 177 minutes. The 30-day complication rate was 28.5%. No patient was lost to follow-up over a mean 25.8 months and the BMI of the 12 patients with a follow-up≥3 months is 33.2±7.2 kg/m2. With reference to the initial weight of the patients, the mean %EWL is 73.5% and %TWL is 37.6±16.0%. On average, patients benefited from a 21.1% TWL through the conversion of their RYGB. ConclusionsThis procedure allows for an easier conversion of RYGB to BPD/DS and appears to be the most effective procedure for resuming weight loss. Nutritional consequences and weight loss are similar to the primary BPD/DS results. However, the benefits and risks must be carefully assessed according to the definition of weight loss failure.

胆嚢摘出術中にPTGBDより除石したR-Y再建後総胆管結石の1例

胆嚢摘出術中にPTGBDより除石したR-Y再建後総胆管結石の1例

Colon Reconstruction and Esophageal Reconstructive Surgery

Esophageal reconstruction using colon graft was investigated in this review. Since the first use of the colon for esophageal reconstruction by Kelling and Vulliet, the colon reconstruction became a reliable surgical option to reconstruct partially or totally the esophagus. Over the time, the efficacy of colon graft has been thoroughly evaluated and definitively attested by competent surgeons during the past three decades. The mortality has been significantly improved however the early morbidity is still slightly higher compared to gastric reconstruction. Despite the increased operative time and number of anastomoses, the advantages of a colon graft become apparent including its relatively straight mesentery, its status as an enough long graft to be pulled up to the neck, its low incidence of disease, its resistance gastroesophageal reflux and its long-term good functional results. Compared to right colon, the left colon has less variation in blood supply and a smaller lumen diameter which matches perfectly with esophageal lumen. Colon reconstruction in an isoperistaltic fashion is the standard in order to prevent regurgitation and improve food transit. The posterior mediastinum and the substernal route are the most commonly route used in esophageal reconstruction. However in case of substernal colon reconstruction, as recommended by authors, the thoracic inlet should be enlarged by the partial remove of the manubrium and the left clavicle to ensure there is no compression on the transposed graft at the level of the thoracic inlet. The selection of appropriate colon graft should be based on the adequacy of blood supply and the length of reconstruction. Thereafter microvessel anastomosis should be added in cases where graft ischemia might occur.

Laparoscopic intracorporeal stapling of the gastric tube on the basis of surface blood supply after minimally invasive esophagectomy

Background/IntroductionMinimally invasive esophagectomy is a complex operation in which creating a healthy gastric substitute is crucial. The present study evaluated a novel method of reconstructing the intracorporeal laparoscopic gastric tube on the basis of surface blood supply to the stomach. PurposeTo study the feasibility and safety of a novel method of laparoscopic gastric tube reconstruction. MethodsAfter the complete mobilization of the stomach, the stomach was intracorporeally stapled along the watershed area between the blood supplies of the lesser and greater curvatures. Subsequently, the gastric tube was pulled up to the neck for end-to-side cervical esophagogastrostomy. Perioperative data were prospectively collected for the first 20 patients who had undergone this novel laparoscopic gastric reconstruction at our institute. The descriptive statistics are reported in this paper. ResultsWe enrolled 20 patients (18 men and 2 women) with esophageal cancer who were admitted to the Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan between January 2013 and December 2013. The mean operative time was 7.10 ± 1.08 hours, and the mean operative blood loss was 118.00 ± 79.71 mL. The average length of the gastric tubes above the sternal notch was 7.65 cm (∼5.0–15.0 ± 2.40 cm); the average width of the gastric tubes was 3.74 ± 0.47 cm. No case required conversion to open surgery, and only one patient (5%) experienced a minor anastomotic leak. The overall complication rate was 45% (predominantly involving postoperative transient hoarseness), and no surgical mortality was observed in this study. ConclusionTotal laparoscopic intracorporeal gastric tube reconstruction based on anatomical characteristics of the surface blood supply to the stomach is safe and feasible.

PWE-158 Magnetic sphincter augmentation broadens the appeal of surgical intervention in chronic reflux sufferers

Introduction Magnetic bead oesophageal sphincter augmentation device (MSAD) offers an alternative to tissue fundoplication (TF) in the management of gastro oesophageal reflux disease (GORD). This study evaluates patient decision pathways in selecting one of these surgical options and quality of life based outcomes. Method Consecutive patients with chronic GORD who underwent surgical intervention for definitive treatment were enrolled in the study. The selection criteria for MSAD procedure included objective evidence of GORD, good oesophageal motility, absence of a large hiatus hernia and long segment Barrett’s oesophagus. Pre-operative symptoms, oesophageal physiology, pre-operative and one year post-operative reflux related quality of life scores (HRQL) and the reason for selection of a surgical technique were obtained from a prospective database. Comparative analysis between the MSAD and the TF group was performed. Results A total of 80 patients were included in the study. Forty six patients were suitable for MSAD, of which 44 (96%) elected to undergo the procedure. Thirty four patients failed to meet the inclusion criteria for MSAD and underwent TF, along with 2 patients who preferred to be treated with TF despite suitability for MSAD. Distal oesophageal acid exposure was significantly higher in the TF group (DeMeester score median 52.6 [22–74]) than in the MSAD group (DeMeester score median 34.4 [16–55] (p = 0.011). The HRQL score however were similar for both groups (TF 23.9; MSAD 25.8; p = 0.55). MSAD patients felt the main reason for choosing the procedure was becasue it was less invasive,(30/44, 71%) and secondarily because they perceived it to be associated with less side effects (5/44, 11%). In the TF group 24 patients (64%) felt that the surgeon had influenced their choice of procedure, of which 22 (94%) would have chosen MSAD had they been suitable. Four patients however (11%) chose TF because it was an established procedure with extensive experience. Conclusion Suitability for MSAD was found in 57.5% of patients with objective evidence of GORD. The perception that it represents a less invasive, less problematic but definitive procedure, is an attractive option for patients who may not otherwise have considered more radical surgery. There was no clear correlation with the extent of distal oesophageal acid exposure and the impact of this on patient health related quality of life, suggesting that debilitating symptoms can still occur with relatively modest degrees of reflux. The option of MSAD as a sphincter augmentation rather than a gastric reconstruction procedure may broaden the spectrum of patients willing to undergo surgical rather than medical therapy. Disclosure of interest None Declared.

An Improvement of an Ileus in the Jejunal Pouch by Aspiration with the Overtube of a Balloon Endoscopy: A Case Report

We report a case of an 86-year-old Japanese woman diagnosed with a food-induced ileus whose condition improved by aspiration with the overtube of a balloon endoscopy. She had undergone a total gastrectomy for gastric cancer and reconstruction by Roux-en Y anastomosis and jejunum pouch 17 years earlier. She complained of constipation and loss of appetite lasting more than 1 wk before admission. Her left abdomen showed gradual fullness, and tenderness was also found at the same site. Contrast computed tomography (CT) of the abdomen showed that the jejunal pouch lumenwas markedly expanded by food residue and was pressed into the intestinal tract of the small intestine. Gastrointestinal endoscopy revealed that the food residue was fluid and flowed back up into the esophagus, and the jejunum pouch was filled with food residue. As the patient was elderly, we attempted to aspirate the food residue with the overtube of a balloon endoscopy device. Food-induced ileus has been improved by surgery in the past; however, in determining treatment for ileus it is always necessary to consider the individual patients’ conditions, including the gastrointestinal contents.

Pouch size influences clinical outcome of pouch construction after total gastrectomy: a meta-analysis.

To assess the clinical significance of pouch size in total gastrectomy for gastric malignancies. We manually searched the English-language literature in PubMed, Cochrane Library, Web of Science and BIOSIS Previews up to October 31, 2013. Only randomized control trials comparing small pouch with large pouch in gastric reconstruction after total gastrectomy were eligible for inclusion. Two reviewers independently carried out the literature search, study selection, data extraction and quality assessment of included publications. Standard mean difference (SMD) or relative risk (RR) and corresponding 95%CI were calculated as summary measures of effects. Five RCTs published between 1996 and 2011 comparing small pouch formation with large pouch formation after total gastrectomy were included. Eating capacity per meal in patients with a small pouch was significantly higher than that in patients with a large pouch (SMD = 0.85, 95%CI: 0.25-1.44, I(2) = 0, P = 0.792), and the operative time spent in the small pouch group was significantly longer than that in the large pouch group [SMD = -3.87, 95%CI: -7.68-(-0.09), I (2) = 95.6%, P = 0]. There were no significant differences in body weight at 3 mo (SMD = 1.45, 95%CI: -4.24-7.15, I(2) = 97.7%, P = 0) or 12 mo (SMD = -1.34, 95%CI: -3.67-0.99, I(2) = 94.2%, P = 0) after gastrectomy, and no significant improvement of post-gastrectomy symptoms (heartburn, RR = 0.39, 95%CI: 0.12-1.29, I(2) = 0, P = 0.386; dysphagia, RR = 0.86, 95%CI: 0.58-1.27, I(2) = 0, P = 0.435; and vomiting, RR = 0.5, 95%CI: 0.15-1.62, I(2) = 0, P = 0.981) between the two groups. Small pouch can significantly improve the eating capacity per meal after surgery, and may improve the post-gastrectomy symptoms, including heartburn, dysphagia and vomiting.

Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy

Reconstruction following pharyngolaryngectomy with total esophagectomy is a challenging surgery to perform. Between April 2008 and August 2012, three types of modified gastric pull-up reconstruction procedures, including a gastric tube creation combined with a free jejunal transfer (n = 7), elongated gastric tube creation with vascular anastomoses (n = 2) and pedunculated gastric tube creation with Roux-en-Y anastomosis (n = 5), were performed after pharyngolaryngectomy with total esophagectomy. To clarify feasibility of these reconstructive methods, we retrospectively analyzed the short-term outcomes. There were no graft failures. Salivary fistulae were observed in two cases after high pharyngoenteral anastomoses due to oropharyngeal extension of hypopharyngeal cancers. Overall morbidity rate was 21.4%, and no deaths occurred. Although the operation time was shortest for pedunculated gastric tube reconstructions, morbidity rates were similar among all methods. All three types of modified gastric pull-up reconstruction procedures can be performed safely. We can choose one of these methods according to the tumor status and the patient condition, understanding advantages and disadvantages of each procedure.

Gastroenteric Reconstruction Route After Pancreaticoduodenectomy: Antecolic Versus Retrocolic

IntroductionDelayed gastric emptying (DGE) is a relatively common complication after cephalic pancreaticoduodenectomy (CPD). Its origin is not very clear, and it is believed that its appearance is due to multiple factors (hormones, appearance of other complications, particularly pancreatic fistulas, and the surgical technique). Among the technical aspects associated with DGE, it has been proposed that the route of gastroenteric reconstruction (antecolic or retrocolic) could have an effect on its incidence. Materials and methodsA systemic review was made of the literature, searching for articles that compared both reconstruction routes after CPD, finding only 11 articles: 4 randomized clinical trials, one prospective study, and 6 retrospective studies. A meta-analysis could not be performed on them, due to the large methodological differences between them. ResultsIn the 4 randomized studies, 2 were in favor of the antecolic route, and 2 did not observe any differences between either of them. The antecolic route obtained a much lower DGE rate than the retrocolic one in the only prospective study. In 4 of the retrospective studies the antecolic route obtained a very low rate. The results of both routes were similar in another 2 retrospective studies, with the retrocolic route slightly better in one of them. ConclusionsUsing the published literature, the gastric reconstruction route associated with less DGE after CPD cannot currently be determined.

Ruta de reconstrucción gastroentérica tras duodenopancreatectomía: antecólica versus retrocólica

IntroductionDelayed gastric emptying (DGE) is a relatively common complication after cephalic pancreaticoduodenectomy (CPD). Its origin is not very clear, and it is believed that its appearance is due to multiple factors (hormones, appearance of other complications, particularly pancreatic fistulas, and the surgical technique). Among the technical aspects associated with DGE, it has been proposed that the route of gastroenteric reconstruction (antecolic or retrocolic) could have an effect on its incidence. Material and methodsA systemic review was made of the literature, searching for articles that compared both reconstruction routes after CPD, finding only 11 articles: 4 randomised clinical trials, one prospective study, and 6 retrospective studies. A meta-analysis could not be performed on them, due to the large methodological differences between them. ResultsIn the 4 randomised studies, 2 were in favour of the antecolic route, and 2 did not observe any differences between either of them. The antecolic route obtained a much lower DGE rate than the retrocolic one in the only prospective study. In 4 of the retrospective studies the antecolic route obtained a very low rate. The results of both routes were similar in another 2 retrospective studies, with the retrocolic route slightly better in one of them. ConclusionsUsing the published literature, the gastric reconstruction route associated with less DGE after CPD cannot currently be determined.

The Role of One-Year Endoscopic Follow-Up for the Esophageal Remnant and Gastric Conduit after Esophagectomy with Gastric Reconstruction for Esophageal Squamous Cell Carcinoma

PurposeAfter esophagectomy and gastric reconstruction for esophageal cancer, patients suffer from various symptoms that can detract from quality of life. Endoscopy is a useful diagnostic tool for evaluating patients after esophagectomy. This observational study was performed to investigate the correlation between symptoms and endoscopic findings one year after esophageal surgery and to assess the clinical usefulness of one-year endoscopic follow-up.Materials and MethodsFrom 2001 to 2008, 162 patients who underwent esophagectomy with gastric reconstruction were endoscopically examined one year after operation.ResultsPatients suffered from the following symptoms: nocturnal cough (n=10), regurgitation (n=7), cervical heartburn (n=3), lump sensation (n=2), dysphagia (n=20) and odynophagia (n=22). Eighty-five (52.5%) patients had abnormal findings on endoscopic examination. Twelve (7.4%) patients had reflux esophagitis, and 37 (22.8%) patients had an anastomotic stricture. Only stricture-related symptoms were correlated with the finding of anastomotic strictures (p<0.001). Two patients had recurrences at the anastomotic sites, and four patients had regional lymph node recurrences with gastric conduit invasion visualized by endoscopy. Newly-developed malignancies in the esophageal remnant or hypopharynx that were not detected by clinical symptoms and imaging studies were reported in two patients.ConclusionOne year after esophagectomy, endoscopic findings were not correlated with clinical symptoms, except those related to stricture. Routine endoscopic follow-up is a useful tool for identifying latent functional and oncological lesions.

Primary adenosquamous carcinoma of the pancreas

Adenosquamous carcinoma of the pancreas is a rare subtype of pancreatic cancer. A 55-year-old female patient was admitted in our hospital for evaluation of her epigastric pain of 2 months duration. On physical examination, there was no jaundice. Diffuse tenderness was present over the right upper quadrant and epigastrium. There was a mass located in the epigastrium. Computed tomography scan of the abdomen showed an 8 × 9 cm solid mass with partly cystic areas in the region of body and tail of the pancreas. Other investigations including liver function tests, complete blood count, and urea and electrolytes were normal. A clinical diagnosis of pancreatic tumor was made. Distal pancreatectomy with gastric reconstruction and small bowel anastomosis with splenectomy was done. Histologically, the tumor was diagnosed as adenosquamous carcinoma of the pancreas with infiltration into the wall of duodenum. Adenosquamous carcinoma of the pancreas is an uncommon variant of exocrine pancreatic cancer which demonstrates characteristic immunoprofile and distinct clinical and pathologic features with a worse prognosis than ductal adenocarcinoma.

A Caliber Persistent Artery (Dieulafoy’s Lesion) which is Associated with an Early-Stage Gastric Stump Cancer Following a Distal Gastrectomy

A 75-years old man was hospitalized with symptoms which suggested gastric cancer. Thirty-eight years ago, he had undergone a Billroth-II gastric reconstruction for a peptic ulcer. At the present admission, he had presented with an eight-month history of recurrent haematemesis, epigastric pain, vomiting, and fatigue. The emergent endoscopy showed a type 0-IIc (superficial depressed) early gastric stump cancer in the anastomotic area and total removal of the gastric remnant and the jejunal segment was performed. The histological examination of the surgical specimen showed a gastric adenocarcinoma that invaded the mucosa and the submucosa, without lymph node metastases (pT1bN0 stage). Besides the tumour, enlarged vessels were observed in the submucosa and the muscularis propria, some of which were thrombotic. The surrounding normal gastric wall also presented submucosal oversized vascular spaces, some of which were protruding through the muscularis mucosae in the mucosal layer. Based on these characteristics and the recurrent haematemesis, a final diagnosis of early gastric stump carcinoma which was associated with Dieulafoy's lesion was made. This association has not yet been reported in the literature and it allowed us to diagnose the gastric stump cancer in a very early stage.

Vascular endothelial growth factor expression following ischemic conditioning of the gastric conduit

The partial devascularization of the stomach, necessary for esophageal reconstruction with a gastric conduit, impairs microcirculation in the anastomotic region of the gastric fundus. Ischemic conditioning of the gastric tube is considered as a possible approach to improve microcirculation in the gastric mucosa. The aim of this study was to investigate whether ischemic conditioning induces neo-angiogenesis in the gastric fundus by expression of vascular endothelial growth factor (VEGF). Twenty patients with an esophageal carcinoma scheduled for esophagectomy and gastric reconstruction were included. To compare VEGF expression before and after ischemic conditioning, preoperative endoscopic biopsies were taken from the gastric fundus. The surgical procedure consisted of two separate steps, the complete gastric mobilization including partial devascularization of the stomach and after a delay of 4-5 days high transthoracic esophagectomy with intrathoracic gastric reconstruction (Ivor-Lewis procedure). The second tissue sample was obtained from the donut of the stapled esophagogastrostomy. For further work-up, preoperative biopsies and the gastric donuts were fixed in liquid nitrogen. Preoperative and intraoperative VEGF expression was measured by quantitative real-time reverse transcription-polymerase chain reaction (VEGF×100/β-actin) and results were compared using Wilcoxon test for paired samples. In all 40 specimens, a distinct expression of VEGF could be detected. Comparing the level of VEGF expression of the preoperative biopsies and postoperative tissue sample, no significant difference could be demonstrated following ischemic conditioning. In this model of ischemic conditioning with delayed reconstruction of 4-5 days, no induction of neo-angiogenesis could be demonstrated by measurement of VEGF expression.