Gastric Tube Reconstruction Research Articles

Anesthesia management for tracheoesophageal fistula closed with a new gastrointestinal occluder device: a case report

BackgroundTracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. A new gastrointestinal occluder device provides treatment for TEF patients. However, TEF-related pneumonia and respiratory failure increase the difficulty of anesthesia management, especially in airway management.Case presentationA 64-year-old man with thoracic esophageal cancer underwent esophagectomy and gastric tube reconstruction one year ago. The patient presented with recurrent cough and sputum after surgery. Gastroscopy revealed a fistula between the esophagogastric anastomotic site and membrane of the trachea. Therefore, the patient received implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy. Airway management under general anesthesia was discussed with an interdisciplinary decision, and cuffed endotracheal tube with an inner diameter of 5.5 mm was chosen. This airway management ensured adequate oxygenation during the operation and provided sufficient space for the operation of the tracheoscope in the trachea. Finally, the TEF disappeared after the operation, and the patient was administered an oral diet on the first postoperative day.ConclusionsThe implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy provides a new treatment for TEF patients. This case report suggests that it is important to select an endotracheal tube with an appropriate inner diameter that can not only meet the requirements of ventilation but also does not affect the operation of tracheoscopy in the trachea.

A case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for recurrent malignant melanoma of the esophagus

BackgroundThe treatment strategy for metastatic lesions of primary malignant melanoma of the esophagus (PMME) is currently determined on a case-by-case basis, based on the National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma. The NCCN guidelines state that resection should be considered in patients with resectable metastatic recurrence. Herein, we report a case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for the metastatic recurrence of PMME.Case presentationA 65-year-old female patient with PMME underwent thoracoscopic subtotal esophagectomy, gastric tube reconstruction via the posterior mediastinal route, and cervical esophagogastric anastomosis. Histopathological examination of the resected specimen revealed that the tumor was PMME with tumor invasion into the muscularis propria and no lymph node metastasis. At the age of 68 years, she developed intestinal invagination due to jejunal metastasis of malignant melanoma and underwent resection of the jejunum. Histopathological examination of the resected specimen revealed two metastases of malignant melanoma in the jejunum and one metastasis to the mesenteric lymph node. At the age of 75 years, a recurrence of malignant melanoma was found in the cervical esophagus. She underwent thoracoscopic mobilization of the gastric tube and esophagus followed by cervical esophagectomy and reconstruction with a free jejunum flap. She received 24 courses of nivolumab therapy for 1 year as a postoperative adjuvant therapy. Subsequently, at the age of 78 years, an enlarged left cervical lymph node and a mass in the right lower lobe of the lung were found. She underwent left cervical lymph node dissection and thoracoscopic wedge resection of the right lung. Histopathological examination of the resected specimens revealed that both tumors were metastases of malignant melanoma. At age 79 years, she received eight courses of nivolumab therapy as a second postoperative adjuvant therapy, with no sign of recurrence in a 9-month follow-up period after the third metastasectomy.ConclusionIn cases of metastatic recurrence of PMME, aggressive resection of oligometastasis with postoperative adjuvant nivolumab therapy may result in long-term survival.

268. COMPARISON OF OUTCOME OF GASTRIC TUBE RECONSTRUCTION FOR ESOPHAGEAL CANCER BETWEEN RECONSTRUCTIVE ROUTES

Abstract The route of gastric tube reconstruction after esophageal cancer resection is generally adopted as either posterior sternal or posterior mediastinal. There have been no large-scale comparative studies, and each institution has chosen a route based on its own experience. Therefore, we conducted an observational study at our institution to compare the postoperative outcomes of posterior sternal and posterior mediastinal reconstruction in gastric tube reconstruction for esophageal cancer. The study included 159 patients with thoracic esophageal cancer who underwent subtotal esophagectomy and gastric tube reconstruction (73 patients in the posterior sternal reconstruction (RS) group and 86 patients in the posterior mediastinal reconstruction (PM) group) from 2016 to 2018 and compared perioperative and postoperative complications and postoperative nutritional status. There were no differences in age, location, or pStage between the reconstructive routes, but BMI was significantly higher in RS (22.0 ± 2.9) and PM (20.8 ± 3.1). Anastomotic leakage (RS:PM = 8%:3%) and respiratory complications (RS:PM = 6%:15%) were not significantly different. PM was also significantly more common with ileus (13%). Anastomotic stenosis requiring dilation was significantly less common in PM than RS (31%:17%, p = 0.04). Weight loss was significantly higher in the RS group at 1 year postoperatively (RS/PM:13.9%/10.2%, p = 0.02). We have changed to PM with gastrostomy and the modified Collard anastomosis. These procedures have decreased the occurrence of ileus due to jejunostomy. Anastomotic stenosis was reduced to 5%. In gastric tube reconstruction after subtotal esophageal resection for esophageal cancer, the reconstructive route (posterior sternal or posterior mediastinal route) showed no significant difference in the incidence of postoperative pneumonia or anastomotic leakage. By changing the anastomotic procedure, a decrease in anastomotic stenosis was observed even with posterior sternal reconstruction. We plan to accumulate more cases and investigate the effects on quality of life and nutritional status in the future.

457. STANDARDIZATION AND SHORT-TERM RESULTS OF ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY

Abstract Surgical cases of robot-assisted thoracoscopic esophagectomy (RAMIE) is increasing because of the advantages of robotic system. We introduced RAMIE in 2019 and standardized the surgical procedure. The usefulness of RAMIE was examined by classifying surgical cases into early and late periods and comparing the surgical results. Fifty-four patients who underwent RAMIE were enrolled in the study. All patients underwent D2 or higher lymph node (LN) dissection, gastric tube reconstruction, and R0 surgery. The patients were divided into two groups, 26 cases in the first half up to December 2020 and 28 cases in the second half after January 2021. The patient background, surgical technique, and short-term results were compared. The tumor staging was based on the UICC 8th version. Thoracic surgery time was 274 minutes, the chest bleeding volume was 30 mL, and the postoperative hospital stay was 19 days (median). In the late stage, patients with clinical thoracic LN metastasis (p = 0.01) and advanced stage (p = 0.006) were higher than those in the early period. There were significantly more cases of thoracic duct resection and D3 dissection in the late period (p = 0.02, p = 0.009). No differences in postoperative complications and intra-hospital death was observed, however the postoperative hospital stay was significantly shortened in the late period (p = 0.001). Thorough mediastinal LN dissection by RAMIE could be safely performed by standardizing and improving the surgical procedures. RAMIE has several issues such as higher cost associated with equipment and longer operative time, but it is possible to perform precise procedures with solo surgery, and it is expected that cost reduction effects will be expected in terms of the number of participants in surgery and the length of hospital stay after surgery.

389. BENEFITS OF BILATERAL THORACOSCOPIC SURGERY IN THE PRONE POSITION FOR A LARGE ESOPHAGEAL TUMOR

Abstract Esophageal gastrointestinal stromal tumors (GISTs) are relatively less symptomatic and may have a significantly large tumor diameter at diagnosis. Large esophageal tumors are difficult to resect because it is tough to maintain the surgical field in the narrow mediastinal region. In addition, because GIST has a risk of dissemination if the tumor collapses during surgery, it must be resected with as little force as possible. We herein report a middle and lower thoracic esophageal GIST with a maximum lateral diameter of 12 cm that could be safely resected by a bilateral thoracoscopic approach in the prone position. The case was that of a 70-year-old man. Since his tumor diameter was large and the surrounding organs were severely compressed, it was deemed to be borderline resectable, and preoperative chemotherapy with imatinib was decided. However, administration of imatinib did not result in tumor shrinkage, and interstitial pneumonia occurred. Thus, the final decision was to resect it. It was difficult to remove the left side of the tumor by normal thoracoscopic operation from the right side as the tumor was large. There was also the risk of the tumor collapsing due to unreasonable traction. Therefore, we selected a surgical procedure in which the left and right sides of the tumor were detached by bilateral thoracoscopic operation in the prone position and then the tumor was removed from the abdominal cavity by a transesophageal hiatal operation under laparotomy. Followed by gastric tube reconstruction by the posterior sternal route. The postoperative course was uneventful. In this case, taking advantage of the thoracoscopic approach from both sides, the tumor could be safely resected without unreasonable traction. Furthermore, the prone position has the advantage that bilateral thoracoscopic operation is possible without changing the position. This technique could also be applied for the excision of esophageal cancer involving the left side.

242. ENDOSCOPIC MUCOSAL CONGESTIVE CHANGE ON POSTOPERATIVE DAY 1 AS A PREDICTIVE FACTOR OF POSTOPERATIVE ANASTOMOTIC STRICTURE

Abstract Anastomotic stricture is one of the crucial complications after the esophageal cancer surgery. Although anastomotic leakage is said to be a risk factor, anastomotic stricture can also occur without anastomotic leakage. From 2008, we have routinely conducted endoscopy on postoperative day 1, and evaluated the anastomotic site or mucosal condition of reconstructed organ. Among these data, we focused on the mucosal congestive change and examined the association with postoperative anastomotic stricture. From 2010 to 2015, 203 esophageal cancer patients were conducted esophagectomy with retrosternal gastric tube reconstruction in Tokyo Medical and Dental University. Among them, 197 patients for which endoscopic data on postoperative day 1 were obtained were included in this study. Mucosal congestion was defined as blue or black color on endoscopic findings, and classified into four groups as absent, mild, moderate, and severe. Univariate and multivariate analysis were performed to clarify the relationship between the mucosal congestive change on endoscopic findings and occurrence of postoperative anastomotic stricture. Among 197 patients, 60 patients (30.4%) experienced postoperative anastomotic stricture. Univariate and multivariate analysis revealed that the mucosal congestive change as moderate or severe was the independent risk factor for postoperative anastomotic stricture along with lower pathological Stage. Circular stapler size used for esophago-gastric anastomosis or postoperative anastomotic leakage were not independent risk factors for postoperative anastomotic stricture in this study. It is said that congestive change induces secondary ischemia because of the high internal tissue pressure, and sometimes causes more severe damage than arterial ischemia. Our postoperative endoscopic evaluation method is useful to detect the risk of developing anastomotic stricture in early postoperative state. In such cases, management of postoperative fluid balance might be important to prevent postoperative anastomotic stricture, but it requires further investigation.

628. THE BEST METHOD OF THE GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY

Abstract As a postoperative complication of esophageal cancer, anastomotic leakage (AL) is a serious complication that affects not only the delay in the start of oral intake but also the prognosis. Anastomotic stenosis (AS) also has a significant effect on postoperative quality of life. The blood flow evaluation of gastric tube was introduced for the purpose of improving these, and then the anastomosis method was changed from hand-sewn to Collard's modified method. Esophageal cancer patients who underwent gastric tube reconstruction as a radical operation for esophageal cancer during the period from January 2017 to November 2021 were included (n=120). The blood flow evaluation of gastric tube using the ICG was started in 2019, and the anastomosis method was changed from hand-sewn to Collard modified method from April 2021. These patients were divided into 3 groups and the surgical results were compared and examined. Group A (without blood flow evaluation, hand-sewn): 55 cases, Group B (with blood flow evaluation, hand-sewn): 42 cases, Group C (with blood flow evaluation, modified Collard method): 23 cases. In the blood flow evaluation of gastric tube, the A and B groups were compared, and the AL incidence rate tended to be higher in the B group (A/B: 18.2%/33.3%, p=0.087). The incidence of AS was significantly higher in group B (A/B: 32.7%/66.7%, p=0.001). There was no difference in the incidence of AL between groups B and C (B/C: 33.3%/26.0%, p=0.586). The incidence of AS was significantly lower in group C (B/C: 66.7%/5.9%, p<0.001). The incidence of AL was compared by anastomotic method, but no difference was observed (P = 0.444). In addition, there was no difference in postoperative complications. It is considered that the modified Collard method could reduce AS because a constant anastomosis diameter could be maintained even when a difference in diameter between the esophagus and the gastric tube was observed during the anastomosis. However, both AL and AS have increased due to the evaluation of gastric tube blood flow, and it is necessary to review the blood flow evaluation method.

400. RISK FACTORS OF DELAYED GASTRIC EMPTYING AFTER ESOPHAGECTOMY WITH GASTRIC INTERPOSITION: AN ANALYSIS OF 810 CASES

Abstract Delayed gastric emptying (DGE) after esophagectomy is not uncommon and would significantly impair patient’s quality of life. Risk factors of DGE remained poorly understood. This study aimed to assess this unresolved issue. We performed a retrospective study in patients with esophageal cancer who underwent esophagectomy and reconstructed with the gastric substitute between 2000 to 2020. DGE was defined as less than 50% emptying of the contrast medium within 10 minutes on postoperative esophagography. Multivariable logistic analysis was performed to identify patient-, tumor- and procedure-related factors that increase the risk of DGE. Among 810 eligible patients, the incidence of DGE was 12.2%. Patients who developed DGE had higher incidence of pneumonia (23.2% vs. 10.7%, p < 0.001), longer hospital stay (25.16vs.19.89 days, p < 0.001), and higher rate of in-hospital mortality (4% vs. 1%, p = 0.014). Multivariate analysis identified pre-existing COPD (OR, 2.38; p = 0.004), whole stomach reconstruction (vs. gastric tube, OR, 6.96; p = 0.001) and posterior mediastinum route (vs. retrosternum, OR, 5.35; p = 0.002) as independent risk factors for DGE. The incidence of DGE was 0.6% in patients who received gastric tube reconstruction via retrosternum route as opposed to 20.6% who received whole stomach reconstruction via posterior mediastinum route. DGE after esophagectomy is associated with increased morbidity and mortality. Type of gastric conduit and route of reconstruction played important roles in the development of DGE.

405. TRANSTHORACIC VERSUS TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGEAL SQUAMOUS CELL CANCER: PROPENSITY SCORE-MATCHED COHORT ANALYSIS

Abstract Transthoracic esophagectomy (TTE) has been the standard procedure for esophageal squamous cell carcinoma (ESCC). In our institution, we performed transmediastinal esophagectomy (TME) as a radical operation for ESCC from 2013. In this study, we compared the short-term and long-term outcome of TME and conventional TTE using propensity score matching analysis. We performed a retrospective cohort study including 223 patients who underwent esophagectomy with gastric tube reconstruction for ESCC between January 2009 and December 2017. Of these, 115 patents underwent TME and 108 patients underwent TTE. Propensity score was calculated using logistic regression analysis and one-to-one patient pairs were matched using propensity score matching. 72 patients in the TME group and TTE group were extracted by propensity score matching. The incidence of postoperative pneumonia was significantly lower in the TME group (9.7% vs 33.3%, P = 0.0004). Three-year overall survival rate was relatively better in the TME group than in the TTE group (75.0% vs 62.6%, P = 0.165). And Three-year recurrence-free survival rate also tended to be better in the TME group than in the TTE group (55.2% vs 48.5%, P = 0.373). TME reduce postoperative pneumonia and may improve long-term prognosis in ESCC patients.

Possibility of ultrathin endoscopy in radial incision and cutting for esophageal strictures.

Video 1The radial incision and cutting procedure using ultrathin endoscopy.

Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction.

This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.

A Comparison of Different Types of Esophageal Reconstructions: A Systematic Review and Network Meta-Analysis.

Background: A total esophagectomy with gastric tube reconstruction is the mainstream procedure for esophageal cancer. Colon interposition and free jejunal flap for esophageal reconstruction are the alternative choices when the gastric tube is not available. However, to date, a solution for the high anastomosis leakage rates among these three types of conduits has not been reported. The aim of this network meta-analysis was to investigate the rate of anastomotic leakage (AL) among the three procedures to determine the best esophageal substitute or the future direction for improving the conventional gastric pull-up (GPU). Methods: We searched PubMed, Cochrane, and Embase databases. We included esophageal cancer patients receiving esophagectomy and excluded patients with other cancer. The random effect model was used in this network meta-analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment of studies in the network meta-analysis, and funnel plots were used to evaluate publication bias. The primary outcome is anastomosis leakage; the secondary outcomes are stricture formation, length of hospital stays, and mortality rate. Results: Nine studies involving 1613 patients were included in this network meta-analysis. The trend results indicated the following. Regarding anastomosis leakage, free jejunal flap was the better procedure; regarding stricture formation, colon interposition was the better procedure; regarding mortality rate, free jejunal flap was the better procedure; regarding length of hospital stay, gastric pull-up was the better treatment. Discussion: Overall, if technically accessible, free jejunal flap is a better choice than colon interposition when gastric conduit cannot be used, but further study should be conducted to compare groups with equal supercharged patients. In addition, jejunal flap (JF) cannot replace traditional gastric pull-up (GPU) due to technical complexities, more anastomotic sites, and longer operation times. However, the GPU method with the supercharged procedure would be a possible solution to lower postoperative AL. The limitation of this meta-analysis is that the number of articles included was low; we aim to update the result when new data are available. Funding: None. Registration: N/A.

Clinical effect of home enteral tube feeding supplementation on nutritional status after esophagectomy with retrosternal gastric tube reconstruction.

Body weight loss and poor nutritional status are frequently observed after esophageal cancer surgery. The aim of this study was to pilot an investigation on the impact of home enteral tube feeding supplementation (HES) for up to 3months after esophageal cancer surgery. We retrospectively reviewed consecutive 67 esophageal cancer patients who underwent esophagectomy with gastric tube reconstruction. We started HES from April 2017. The patients were divided into 2 groups. Among 67 patients, 40 patients underwent HES between April 2017 and November 2020 (HES group). Other 27 patients who underwent esophagectomy between January 2012 and March 2017 were not administered HES (C group). Thereafter, multiple factors concerning patient nutritional status at long-term follow-up were evaluated. The baseline characteristics were balanced between the two groups. There were no significant differences in nutritional status scores before esophagectomy. The percentage weight loss was less in the HES group compared with the C group both at 3months and 1year after surgery: 7.3% (-7.6 to 15.2), 7.7% (-4 to 13.9) in the HES group and 10.6% (-3.6 to 29.1), 10.8% (-5.8 to 20.0) in C group (P < 0.05, P < 0.05). In the patients with anastomotic stenosis, the percentage weight loss was less in the HES group compared with the C group: 7.2% (2.0-14.9) and 14.6% (6.2-29.1), P < 0.05. HES may improve early weight loss in postesophagectomy patients.

A survey of the clinical outcomes of cervical esophageal carcinoma surgery focusing on the presence or absence of laryngectomy using the National Clinical Database in Japan.

One upside of cervical esophageal carcinoma is that radical surgery can be performed by laryngectomy, even for tumors with tracheal invasion. However, this approach drastically reduces the quality of life, such as by losing the vocal function. Cervical esophageal carcinoma is rare, and no comprehensive reports have described the current state of surgery. Using a Japanese nationwide web-based database, we analyzed the surgical outcomes of cervical esophageal carcinoma to evaluate the impact of larynx-preserving surgery. Based on the Japan National Clinical Database, 215 surgically treated cases of cervical esophageal carcinoma between January 1, 2018, and December 31, 2019, were enrolled. Clinical outcomes were compared between the larynx-preserved group and the laryngectomy group. Ninety-four (43.7%) patients underwent larynx-preserving surgery. A total of 177 (82.3%) patients underwent free jejunum reconstruction. More T4b patients and more patients who underwent preoperative radiotherapy were in the laryngectomy group. There were no significant differences in the frequency and the severity of morbidities between the two groups. However, in the laryngectomy group, in-hospital death within 30days after surgery was observed in 1 patient, and the postoperative hospital stay was significantly longer (P = 0.030). In the larynx-preserved group, recurrent nerve paralysis was observed in 24.5%. Re-operation (35.3%, P = 0.016), re-intubation (17.6%, P = 0.019) and tracheal necrosis (17.6%, P = 0.028) were significantly more frequent in patients who underwent pharyngolaryngectomy with total esophagectomy and gastric tube reconstruction than in others. Larynx-preserving surgery was therefore considered to be feasible because it was equivalent to laryngectomy regarding the short-term surgical outcomes.

Postoperative Nutrition Status of Patients With Esophago-gastric Junction Cancer With Gastric Tube or Esophago-gastric Reconstruction.

Postoperative nutritional management for esophago-gastric junction cancer (EGJC) has become increasingly important. This study compared the nutritional status of patients with EGJC who underwent gastric tube reconstruction versus esophago-gastric anastomosis. Mediastinoscopic esophagectomy with gastric tube reconstruction was performed in 17 cases (group GT) and laparoscopic proximal gastrectomy with esophago-gastric anastomosis in 33 cases (group EG). The perioperative characteristics and nutritional status of the two groups in the 2 years postoperatively were compared. Group GT had a significantly higher level of serum total protein at 24 months postoperatively than did group EG. No other significant differences in postoperative nutritional status were observed between the groups. Gastric tube reconstruction for EGJC was not inferior to esophago-gastric anastomosis in terms of nutritional status. It is a candidate surgical procedure to avoid higher mediastinal anastomosis.

Upper Gastrointestinal Obstruction Caused by a Cystic Mimicker

Question: A 65-year-old man with no past medical history presented to our hospital with dysphagia. Esophagogastroduodenoscopy revealed hemorrhagic irregular mucosa with stenosis in the esophagus (Figure A), which was diagnosed as squamous cell carcinoma (SCC) by pathologic examination. After fluorouracil and cisplatin were dosed as neoadjuvant chemotherapy, the patient underwent a subtotal esophagectomy with gastric tube reconstruction. Postoperative pathological examination revealed moderately differentiated SCC with lymph node metastasis.

Anti-reflux gastrointestinal reconstruction techniques after laparoscopic proximal gastrectomy

Laparoscopic techniques are more and more poplular in proximal gastrectomy. The traditional esophagogastric anastomosis may lead to severe reflux esophagitis after surgery, affecting patient's quality of life. In recent years, multiple methods of digestive tract reconstruction after laparoscopic proximal gastrectomy capable of resisting reflux have been applied to the clinic. Combining the results of the latest clinical studies and our clinical experience, we elaborate the views on digestive tract reconstruction after laparoscopic proximal gastrectomy. Esophagogastric anastomosis (posterior esophagogastric anastomosis, anterior esophagogastric anastomosis, gastric tube reconstruction, lateral esophagogastric anastomosis, Kamikawa anastomosis and modified Kamikawa anastomosis, etc.) and esophagojejunal anastomosis (interposition jejunum, interposition jejunum with pouch, and double-channel anastomosis, etc.) are mainly discussed. Of course, the anti-reflux mechanisms of different surgical procedures are not the same, the anti-reflux effects are variable, and the surgical difficulties under laparoscopy are also different. Therefore, how to choose a rational reconstruction method after proximal gastrectomy needs to be comprehensively considered based on patient's own situation and technical level of the surgeons.

Left thoracoscopic approach in the supine position for torsion of the residual esophagus after esophagectomy: a case report

BackgroundAnastomotic stenosis can occur after esophagectomy and gastric tube reconstruction. The effective surgical treatment for refractory anastomotic stenosis, which seems difficult to resolve with endoscopic treatment, has not been established. We report a case of refractory stenosis due to esophageal torsion in which reconstructive surgery was possible using a left thoracoscopic approach in the supine position.Case presentationA 72-year-old man who underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer 6 months previously presented to us. Postoperative endoscopy revealed that the residual esophagus was twisted approximately 360°, just above the anastomotic site. Conservative endoscopic treatment failed to improve the condition due to severe passage obstruction, and reconstructive surgery was repeated. Surgery was performed in the supine position using a left thoracoscopic approach. The entire circumferences of the gastric tube and residual esophagus were dissected from the inferior mediastinum to the top of the sternum, with focus on preserving the right gastroepiploic vein and gastric-tube wall. Subsequently, laparoscopic surgery was performed to remove the gastric tube from the thoracoabdominal junction. After separating the esophagus on the oral side of the torsion from the left cervical wound, the abdomen was opened, the gastric tube was pulled out through the abdominal wound, and adhesions in the abdominal cavity were peeled off to raise the gastric tube cranially via the retrosternal route. An end-to-side anastomosis was performed using a circular stapler, and the esophageal torsion and previous anastomosis were resected. Oral intake was resumed on the 7th postoperative day, and the patient was discharged on the 38th day.ConclusionsAfter subtotal esophagectomy and retrosternal gastric tube reconstruction, the left thoracoscopic approach is one of the most minimally invasive approaches and is especially useful for preserving the right gastroepiploic artery and veins and for mobilizing the gastric tube wall.

A right pulmonary vein abnormality treated with 3D CT assistance in thoracoscopic surgery for esophageal cancer: a case report

BackgroundAnomalous bifurcation of the right superior pulmonary vein is an important anomaly that should be recognized not only in respiratory and cardiac surgeries, but also in esophageal surgery for the safe performance of surgery. We report a case in which thoracoscopic esophagectomy was safely performed using preoperative three-dimensional computed tomography (3D CT) imaging.Case presentationAn 81-year-old male patient received an upper gastrointestinal endoscopy, which revealed a 20-cm incisor at the entrance, 43-cm EGJ, and 30-mm large type 1 + IIc lesion between the 23-cm and 26-cm incisors; biopsy showed squamous cell carcinoma (SCC). Contrast-enhanced CT showed wall thickening in the anterior wall of the upper thoracic esophagus, without evidence of multi-organ invasion or lymph node metastasis. In addition, a break in the right pulmonary vein passing dorsal to the right main bronchus and flowing directly into the left atrium was observed, and 3D CT was performed preoperatively to confirm the 3D positioning. Positron emission tomography (PET)–CT showed a high degree of accumulation (SUVmax 19.95) in the upper thoracic esophagus. The patient was diagnosed with upper thoracic esophageal cancer, cT2N0M0 cStage II, and underwent thoracoscopic subtotal esophagectomy (three-region dissection) and gastric tube reconstruction. The dorsal inflow of the pulmonary vein in the right main bronchus, which was recognized on preoperative CT, was confirmed and preserved. The pathological diagnosis was basaloid squamous cell carcinoma, pT1b(SM1)N0(0/58)M0 pStage I. The postoperative course was uneventful, and the patient was discharged on postoperative day 20.ConclusionsThe anomalous bifurcation of the pulmonary vein in the right upper lobe area required attention because of its potential to cause massive bleeding and difficulty in securing the operative field if misidentified and damaged during surgery. Although it is not frequently encountered, it is the bifurcation anomaly that esophageal surgeons must bear in mind due to its severe consequences. Preoperative image-reading and intraoperative manipulation of this vessel are imperative for surgical safety.

Near-infrared fluorescence imaging with indocyanine green to assess the blood supply of the reconstructed gastric conduit to reduce anastomotic leakage after esophagectomy: a literature review.

The blood supply of the right gastroepiploic artery after esophagectomy with gastric tube reconstruction is essential for avoiding anastomotic leakage. Near-infrared fluorescence (NIRF) imaging with indocyanine green is widely used to assess the blood supply because it can visualize it in real-time during navigation surgery. However, there is no established protocol for this modality. One reason for this lack of protocol is that NIRF provides subjective information. This study aimed to evaluate NIRF quantification. We conducted a literature review of risk factors for anastomotic leakage after esophagectomy, NIRF procedures, NIRF quantification, and new methods to compensate for NIRF limitations. Major methods for the quantification of NIRF include measuring the blood flow speed, visualization time, and fluorescence intensity. The cutoff value for the blood flow speed is 2.07cm/s, and that for the visualization time is 30-90s. Although the time-intensity curve provided patterns of change in the blood flow, it did not show an association with anastomotic leakage. However, to compensate for the limitations of NIRF, new devices have been reported that can assess tissue oxygenation perfusion, organ hemoglobin concentration, and microcirculation.