Gastroepiploic Vessels Research Articles

Adenocarcinoma with Neuroendocrine Differentiation of the Colon Accompanying Osteoclast-Like Giant Cells

Introduction. Neuroendocrine differentiation in colorectal cancer is reportedly associated with poorer grade of tumor differentiation, nodal and distant metastasis, and other unfavorable features, contributing to a worse clinical outcome. Colorectal cancer with osteoclast-like giant cells (OGCs) is extremely rare. Case Presentation. An 86-year-old woman was diagnosed as double cancer of the transverse and sigmoid colon. Both tumors were simultaneously removed. The transverse colon cancer directly invaded the area of the right gastroepiploic vessels and spread to the nodes and histologically consisted of both the tubuloglandular and solid components. CD8/granzyme B-positive tumor-infiltrating lymphocytes and CD163/CD68-positive macrophages, frequently forming OGCs, were observed particularly at the invasion front. The carcinoma cells were labeled focally for synaptophysin and diffusely for the DR locus of the human leukocyte antigen and programmed death-ligand 1 (PD-L1). Deficient expression of DNA mismatch repair (dMMR) proteins was immunohistochemically confirmed. The patient died 16 months after surgery. Conclusion. This is the first report of colonic adenocarcinoma with neuroendocrine differentiation accompanying OGCs. Histopathologic factors of the poor prognosis in the present case included (a) the presence of more than 2% cells with neuroendocrine differentiation, (b) infiltration of CD163/CD68-positive OGCs at the invasion front, (c) deficiency of dMMR proteins, and (d) PD-L1 expression.

Use of an Omental Flow-Through Flap for Recipient Vessels in the Reconstruction of a Lumbar Spine Defect

Spine reconstruction after en bloc spondylectomy is challenging and may require multidisciplinary intervention. En bloc spine tumor resection with embolization of local recipient vessels for tumor control limits reconstructive options. Herein, we describe a case where combined efforts from orthopaedic, general, and plastic surgery teams permitted the successful reconstruction of a multilevel lumbar vertebral defect. A fibula-free flap within a titanium cage construct anastomosed to the left gastroepiploic vessels via a pedicled omental flow-through flap is a viable and novel method for reconstruction of a multilevel vertebral defect.

P155 REAL-TIME EVALUATION OF THE GASTRIC CONDUIT BASED ON THE REGIONAL O2 SATURATION (%) AND TOTAL HEMOGLOBIN INDEX IN THORACIC ESOPHAGECTOMY

Abstract Aim Evaluation of blood supply of gastric conduit is one of the most importance parameter in thoracic esophagectomy. Evaluation with indocyanine green is the most popular evaluation method. However, indocyanine green does not objecctive values with Herein we introduce the new evaluation method based on the regional SO2(%) and Total hemoglobin index in thoracic esophagectomy. Background and methods: Between February to July 2018, we evaluated 56 patients underwent thoracic esophagectomy for esophageal cancer. Regional O2 saturation level (rSO%) and total hemoglobin indexes (T-HbI) of gastric conduit was evaluated using the ToccareTM (ASTEM Co. Ltd Tokyo, Japan) to determine the optimal site of anastomosis on gastric conduit. Results Fifty-two patients were eligible in this study. Mean value of the rSO2(%)/T-HbI were 57.6%/0.22 at the anal side of the gastric conduit where sufficient feeding arteries were existed from right gastroepiploic artery and vein. On the other hand, mean values of the rSO2(%)/T-HbI were 59.4%/0.28 (p<0.05) at the distal side of the gastric conduit where direct feeding artery from right gastroepiploic vessel was terminated. Then, mean values of rSO2(%)/T-HbI were 46.3%/0.34 (p<0.05) at the tip of the gastric conduit, which consisted to the gradual congestion was happened prior to the tissue oxygenation in the gastric conduit. There were 1 patient which found anastomotic leakage (1.9%) among 56 patients. Conclusion Evaluation of the regional SO2(%) and total hemoglobin index of the gastric conduit was non-invasiveness procedure and useful to easily determine the optimal site of anastomotic level to minimize the incidence of anastomotic leakage in thoracic esophagectomy.

The influence of anastomosis-induced gastric wall defects on the blood supply to the gastric tube

The influence of anastomosis-induced gastric wall defects on the blood supply to the gastric tube

Vascular injury and anatomy during laparoscopy - assisted distal gastrectomy with D2 lymphadenectomy for gastric cancer

Objective: To evaluate the incidence of intraoperative vascular injury (IVI) and associated anatomical features during laparoscopy - assisted distal gastrectomy (LADG) with D2 lymphadenectomy for gastric cancer. Methods: A descriptive cohort study was performed. Clinical data and operational videos of 278 consecutive gastric cancer patients who underwent LADG with D2 lymphadenectomy for gastric cancer at Department of General Surgery of Nanfang Hospital between January 2010 and December 2017 were retrospectively analyzed. IVI and vascular anatomy during lymphadenectomy were observed and recorded in the following four scenes: scene I: No. 4sb and No.4d of lower left (tail of pancreas) area; scene II: No.6 of lower right (subpyloric) area; scene III: No.5 and No.12a of upper right (suprapyloric) area; scene IV: No. 7, No. 8a, No. 9, No. 11p of central area posterior to the gastric body. IVI was defined as the injury of main perigastric vessel requiring additional procedure for hemostasis such as electrocauterization, gauze compression, clipping or suture. Results: Among 278 patients, 125 (45.0%) had IVI. Two cases of IVI required conversion to open operation and the injuried vascular was left gastric artery (LGA) and right gastric artery (RGA), respectively. Higher incidence of IVI was found in scene II (92/278, 33.1%) and scene IV(39/278, 14.0%). More common IVI was observed in right gastroepiploic vein (RGeV, 57/278, 20.5%) and left gastric vein (LGV, 33/278, 11.9%). The right gastroepiploic vessels were observed in all 278 patients, including 3 (1.1%) cases with 2 RGeVs, and 2 cases with 2 right gastroepiploic arteries (RGeA). RGA was observed clearly in 265 (95.3%) patients, whose ramification pattern was as follows: from proper hepatic artery (PHA, 223/265, 84.2%), from gastroduodenal artery (GDA, 16/265, 6.0%), from left hepatic artery (LHA, 12/265,4.5%), from the crossing of PHA and GDA (8/265, 3.0%), and 6 (2.3%) patients with 2 RGAs simultaneously from PHA and GDA, respectively. The most common injury of RGA (4/12) occurred in LHA. Excluding 2 cases of conversion to open surgery due to intraoperative hemorrhage, among 276 patients, LGV was observed in 270 patients (97.1%), whose drainage pattern was as follows: into the portal vein (PV, 148/270, 54.8%), into the spleen vein (SV, 56/270, 20.7%), into the junction of these two veins (52/270, 19.3%), into left portal vein (LPV, 8/270, 3.0%), meanwhile 6 patients had 2 LGVs simultaneously, including LGVs of 5 cases into PV and SV, and of 1 case into PV-SV junction and SV. The most common IVI was found in those patients with two LGVs (4/6). Conclusions: IVI during LADG with D2 lymphadenectomy is common. The highest risk of IVI is found in scene II and scene IV. Attentions should be paid to anatomic variation of vessels, especially the RGeV, LGV and RGA.

1945 Isolated Gastric Varices as the Sole Manifestation of Renal Cell Carcinoma

INTRODUCTION: Isolated gastric (fundal) varices (IGV) are a consequence of left (sinistral) portal hypertension commonly caused by splenic vein thrombosis (SVT). It occurs when SVT results in a backflow into the collateral short gastric and gastroepiploic vessels. Common causes of SVT include pancreatic and splenic pathologies. Renal cell carcinoma (RCC) is an extremely rare cause, and by itself, RCC is lethal because of the vagueness of its presenting symptoms. CASE DESCRIPTION/METHODS: A 76 year-old male with a past medical history of chronic anemia is presenting with two day history of hematochezia. He denies any personal or family history of colon cancer. He is not on anticoagulation or NSAID regimen. On evaluation, patient was noted to have non-remarkable vital signs. Physical exam was fairly unremarkable. Initial CBC was remarkable for severe anemia with hemoglobin of 6.1. MCV was normal. After routine transfusion, he was evaluated by gastroenterology and underwent an EGD, colonoscopy and capsule endoscopy. EGD was remarkable for 2 cm diameter non bleeding fundic gastric lesion. Colonoscopy and capsule endoscopy were unremarkable except for findings of dark blood in the distal ileum and throughout the colon. Tagged RBC scan was negative. Endoscopic ultrasound was obtained that showed multiple tubal, anechoic structures in the cardia of the stomach consistent with varices. CT abdomen and pelvis then confirmed a giant mass filling the left renal fossa presumably primary renal cell neoplasm with displacement of the pancreas and splenomegaly. CT chest was obtained and confirmed pulmonary nodules likely suggesting metastatic lesions. He then underwent splenectomy and nephrectomy with adjuvant chemotherapy for the metastatic disease. DISCUSSION: Sinistral (left) portal hypertension (SPH) was first outlined by Greenwald and Wasch in 1939. It is a clinical syndrome in which a patient with a patent portal vein and normal hepatic (liver) function tests develops isolated gastric variceal bleeding secondary to splenic vein thrombosis. Interestingly, only two cases have documented renal cell carcinoma as a cause of SPH in the last 30 years. Patients with this condition need to be considered for a prophylactic splenectomy and removal of associated arteries and veins, as well as a total nephrectomy. In this case, with metastatic lesions to his lungs, involving hematology/oncology and general surgery and gastroenterology in the multidisciplinary decision making process would be in his best interest.

Vascularized gastroepiploic lymph node transfer significantly improves breast cancer‐related lymphedema

Vascularized lymph node transfer (VLNT) is a surgical treatment for lymphedema. Multiple methods have been described and each has significant disadvantages. We performed VLNT in patients with upper extremity lymphedema resulting from breast cancer surgery. We used lymph nodes of the greater curvature of the stomach (VLNTg). We describe outcomes of the patients suffering from postmastectomy lymphedema who received VLNTg for treatment of lymphedema. Harvest from the periphery of the left gastroepiploic vessel was conducted. We retrospectively reviewed data of 24 female patients suffering from lymphedema following breast cancer treatment who underwent lymph node transplantation from 2012 to 2017. Axillary lymphadenectomy had been performed in all cases. In 18 patients, upper limb lymphedema was present for at least 1 year (mean = 5.6 years; range, 1-15 years). In 6 patients, it was present for only a few months (mean = 5 months; range, 3-8 months). The greater curvature of the stomach nodes (VLNTg) is an excellent option for the treatment of upper extremity lymphedema because there is no risk of complications and the scar is easily concealed. Improvement from lymphedema can be expected in a majority of patients.

Pylorus-preserving pancreatoduodenectomy preserving the right gastroepiploic vessels following proximal gastrectomy: report of two cases

BackgroundBlood flow of the remnant stomach is supplied via the right gastric and right gastroepiploic vessels after proximal gastrectomy (PG). Whether the remnant stomach can be safely preserved in patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) after PG remains unclear. We herein report two cases in which the remnant stomach was safely preserved by performing PPPD.Case presentationThe first patient, a 76-year-old man, was diagnosed with cancer of the common bile duct and underwent PPPD 2 years after PG for gastric cancer. The remnant stomach and right gastroepiploic vessels were safely preserved. The second patient, a 56-year-old man with a history of PG for gastric cancer 20 years previously, was diagnosed with cancer of the common bile duct and underwent PPPD. We could safely preserve the remnant stomach and right gastroepiploic vessels.ConclusionThe remnant stomach could be preserved in performing PPPD following PG by preserving the right gastroepiploic vessels.

Double Supercharged Jejunal Interposition for Late Salvage of Long-gap Esophageal Atresia.

A variety of surgical techniques exist to manage long-gap esophageal atresia (LGEA), including gastric pull-up (GPU), colonic interposition (CI), jejunal interposition (JI), and distraction lengthening. Salvage reconstruction for late failure of any conduit type is a complex surgical problem fraught with technical difficulty and significant risk. Jejunal interposition can be used as a salvage procedure in the management of LGEA. However, the opposing requirements of conduit length and adequate perfusion make the procedure technically challenging. Chronic comorbidities and abdominal and thoracic adhesions may further complicate these cases. We report a technique for the management of 3 late treatment failures of LGEA using pedicled JI in conjunction with 2 additional arterial and venous anastomoses, or double supercharging. For 2 patients who presented with failed CI, pedicled JI was performed and supercharged to internal mammary vessels as well as vasculature preserved from the prior colonic flap mesentery. The third patient presented with failed GPU and underwent pedicled JI that was supercharged caudally to the gastroepiploic vessels and cranially to the left common carotid artery. No flaps were lost in any patients. Median operation time was 16.5 hours. Patients were monitored postoperatively in the intensive care unit for a median of 23 days, extubated after 14 days, and discharged at 41 days. Postoperatively, all patients tolerated an oral diet by discharge and continue to enjoy oral intake of all food consistencies without dysphagia or aspiration. Follow-up time spanned 2 to 4 years (average, 3.3 years). One patient required dilatations and temporary stent for stricture, and another required removal of prominent sternal wires; otherwise, no additional procedures were performed. Although technically difficult, double supercharged JI should be considered as a salvage operation to restore esophageal continuity after CI or GPU failure for LGEA, when there are otherwise limited reconstructive options.

Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography.

The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography. A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics. The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery. When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.

Coronary Renal Shunt with Splenectomy (CRSS) for Selective Variceal Decompression

Distal splenorenal shunt and coronary caval shunt are commonly used for selective decompression of esophagogastric varices, but they may not solve severe hypersplenism and their application may be hampered by the presence of splenic venous thrombosis or a left gastric vein (LGV) situated deeply behind the pancreas. On the other hand, some patients have an LGV entering the splenic vein (SV). We tried to work out a new selective shunt for this group of patients. Sixteen patients with severe hypersplenism and esophagogastric varices received coronary renal shunt using the SV following splenectomy. After splenectomy, the proximal portion of the SV and the LGV was isolated from the pancreas. The isolated SV was divided at a point 3-5cm left to its junction with the LGV. The proximal orifice was anastomosed to the left renal vein, and the distal orifice was ligated. A clip was applied to the SV for occlusion between the portal vein and LGV. The right gastric and gastroepiploic vessels were divided to block backflow from the portal vein and to reduce the arterial inflow of the varices. No operative mortality or procedure-related complications occurred. Postoperative computed tomography and endoscopy showed that all the shunts were patent and that the varices had been obliterated or markedly alleviated. In the 6-36months' follow-up period, no recurrent variceal hemorrhage or encephalopathy occurred. Coronary renal shunt combined with splenectomy can achieve the goal of selective decompression of esophagogastric varices. It would become an alternative means of selective variceal decompression for patients whose LGV enters the SV.

PS01.052: OUR STANDARD PROCEDURE IN LAPAROSCOPIC NISSEN FUNDOPLICATION FOR GERD PATIENTS

Abstract Background Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated by many surgeons. We have established our simple procedure. Methods: SURGICAL PROCEDURE Setting Our 5-trocar setting with patients is as follows: 12 mm trocar just below the navel (A), 5 mm trocar at the upper right abdomen for pulling up lateral segment of the liver, 5 mm trocar at the upper right abdomen, 12 mm trocar at the upper left abdomen (B), 5 mm trocar at the middle left abdomen (C). Step 1 Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus of the diaphragma has been dissected free from the soft tissue around the stomach. In this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid unnecessary bleeding. After cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. Then the inside margin of the left crus of the diaphragma was recognized from right side. In this part, laparoscope: trocar (A), the assistant: trocar (B), the operator's right hand: trocar (C). Step 2 The branches of left gastroepiploic vessels and the short gastric vessels were divided. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. In this part, laparoscope: trocar (A) at the beginning of dividing left gastroepiploic vessels, trocar (B) when dividing short gastric vessels. Step 3 The both crus are sutured with interrupted stitches to reduce the hiatus. From the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. Then the fundus of the stomach is pulled to obtain a 360 degree ‘stomach-wrap’ around the abdominal esophagus. Using 2–0 non-absorbable braided suture, stitches are placed between both gastric flaps. Results We have performed this procedure in 90 cases. The mean operation time of recent 20 cases was 90 min. Conclusion We have established our standard anti-reflux surgery procedure with less bleeding and less operative time. Disclosure All authors have declared no conflicts of interest.

PS01.157: APPLICATION OF THE COMPLETELY MOBILIZED REMNANT STOMACH IN ESOPHAGOPLASTY FOR LOWER THORACIC ESOPHAGEAL CARCINOMA FOLLOWING DISTAL GASTRECTOMY

Abstract Background Reconstruction of the esophagus for the patients following distal gastrectomy (DGE)is a significant challenge for surgeons. Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE. Methods The clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II. Results No perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4). Conclusion The completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication. Disclosure All authors have declared no conflicts of interest.

Application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric carcinoma

Objective To investigate the application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 6 patients with esophageal and gastric cancer who were admitted to the General Hospital of Jinan Military Area of PLA between January 2013 and December 2016 were collected. Among 6 patients, 2 and 4 were respectively confirmed as mid-thoracic and low esophageal cancers; tumors of 4 and 3 patients were respectively located in the gastric antrum and gastric body at lesser curvature side, including 1 with tumor in the gastric antrum and body. Esophageal cancer and gastric tumor were simultaneous resected, and proximal stomach replaced esophagus resected, with a blood-supply through right gastroepiploic vessels. There was an anastomosis between proximal tubular stomach and esoghagus. According to resection extent of resection extent, distal anastomosis included: (1) tubular stomach-duodenum BillrothⅠ anastomosis in case 1; (2) tubular stomach-jejunum Billroth Ⅱ anastomosis in case 2, 3 and 4; (3) tubular stomach-jejunum Billroth Ⅱ anastomosis + jejunum-jejunum side-to-side anastomosis in case 5 and 6. Observation indicators: (1) intra- and post-operative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and quality of life up to May 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative recovery situations: 6 patients underwent successful operation. The operation time, volume of intraoperative blood loss, gastrointestinal function recovery time, drainage-tube removal time and duration of hospital stay were respectively (206±50)minutes, (106±24)mL, (3.8±2.1)days, (6.8±5.0)days and (12.5±4.2)days. Of 6 patients, 1 with postoperative aspiration pneumonia and 1 with incomplete intestinal obstruction were cured by medical treatment. There was no anastomotic complication. (2) Postoperative pathological examination: number of lymph node dissectted of 6 patients was 13±3. Case 2 had intra-abdominal lymph node metastasis. Pathological type: esophageal cancers were comfirmed as squamous cell carcinomas, gastric tumor were comfirmed as adenocarcinomas in 5 patients and stromal tumor were in 1 patient. (3) Follow-up and survival situations: 6 patients were followed up for 5-28 months, with a median time of 14 months. During the follow-up, case 1 had severe symptom of reflux, and other 5 patients didn′t have symptoms of reflux. Case 2 died of abdominal metastasis at 11 months postoperatively, and other 5 patients had survival. Conclusion Tubular gastric interposition replacing esophagus resected is safe and feasible in esophageal and gastric cancer, easy to operate and consistent with the physiological characteristics, meanwhile, it will provide opportunities and options of radical resection. Key words: Esophageal neoplasms; Gastric neoplasms; Radical resection; Tubular stomach; Interposition; Digestive tract reconstruction

The completely mobilized remnant stomach: A new choice to reconstruct the esophagus in lower thoracic esophageal carcinoma with a history of distal gastrectomy

ObjectiveIt is a significant surgical challenge to reconstruct esophagus for the patients following distal gastrectomy (DGE). Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE. MethodsThe clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II. ResultNo perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4). ConclusionThe completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication.

Immediate Breast Reconstruction with Laparoscopic Harvested Omental Flap after Breast Cancer Surgery

Here we present a rarely used technique for breast reconstruction after complete or subtotal subcutaneous mastectomy for breast cancer utilizing a laparoscopically harvested omental flap. The procedure was performed in selected patients with multicentric carcinomas, large, central tumors (also post treatment with neoadjuvant chemotherapy), tumors with extensive intraductal components, diffuse carcinomas in situ and in patients desiring the procedure. To date, 65 of these procedures (39 complete and 26 partial mastectomies) have been performed. After the sentinel node biopsy, laparoscopy was performed in order to estimate the size of the omentum. The omentum was dissected, preserving the right gastroepiploic vessels as the pedicle of the omental flap. After performing the subcutaneous mastectomy through an infra mammary incision, a subcutaneous tunnel was created, and the omentum pulled out through a 2-3 cm paraxyphoidal incision, and placed within the breast defect. The cosmetic result was excellent to satisfactory in the majority of cases. There was one loss of the omental flap due to fat necrosis, and one gastric perforation was managed laparoscopically. In three patients, an additional augmentation with lipofilling became necessary. Small skin necrosis could be conservatively treated. Postoperative radiation in patients with positive lymph nodes and subtotal mastectomy was performed without complications. There was no local recurrence to date. In selected patients, this technique produces good results, creating a breast with a natural, soft consistency, and with minimal donor site morbidity. It provides an esthetically appealing supplement to the established methods. Difficulties include preoperative estimation of the size of the omentum. However, if the volume should be inadequate in the beginning, it frequently increases within the first six months. Also this technique can only be applied for unilateral reconstruction.

Abstract: Anatomic Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomography Angiography (CTA)

INTRODUCTION: The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer (VLNT). The actual anatomic details related to the gastroepiploic vascular axis and lymph nodes (LN) have not been investigated. The purpose of this study is to describe the right gastroepiploic artery (GEA) and related structures by using computed tomography angiography (CTA). METHODS: A retrospective analysis was conducted on ten patients with no known abdominal or pelvic malignancy who received CTA. These scans were reviewed for objective donor-site characteristics by one reviewer (CH). Statistical models were used to identify the specific LN basin and right GEA characteristics. RESULTS: The right GEA was identified in nine of ten patients. It was found to have an average diameter of 2.98mm at its origin (SD0.89, range 1.7–4.4). The distance from right to left GEA origin was 17.9cm (SD6.34, range 10.3–29.9). The gastroduodenal artery length prior to right GEA takeoff was 3.78cm (SD1.29, range 2.19–5.92). Nine patients had identifiable lymph nodes in the right GEA lymphosome. There were 3.3 LNs identified per patient (SD3.0, range 0–10). The average distance from each LN to the right GEA origin was 7.50cm (SD3.51, range 2.04–15.4). The distance from the right GEA origin to the most proximal LN was 4.13cm (SD1.65, range 2.04–7.13). The distance from the GEA origin to the third LN was 8.91cm (SD2.90, range 7.11–13.2). Each LN was within 8.55mm (SD7.9, range 1–28.7) of the right GEA. CONCLUSION: The gastroepiploic VLNT may be a valuable option when selecting a donor site for the surgical treatment for lymphedema. On average, three lymph nodes exist along the right GEA, which is comparable to other favorable and commonly used donor sites. When using the right GEA donor site for VLNT, the plastic surgeon should anticipate using a pedicle length of no more than 4cm, a total flap length of 9cm with a 3cm cuff of tissue in order to obtain at least 3 lymph nodes for transfer. CTA is an effective imaging modality that can be used to preoperatively plan for vascularized lymph node transfer.

Use of 1.32-μm and 1.06-μm wavelength lasers for vascular cutting in a porcine model of liver and stomach bleeding ⁎

Abstract Objective The aim of this study was to analyze and evaluate 1.32-μm and 1.06-μm neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers for use in liver and gastroepiploic vessel vaporization and coagulation. Methods The effects of 1.32-μm and 1.06-μm Nd:YAG lasers were compared for gastroepiploic vessel hemostasis in porcine liver. Results The results were observed and measured under the same parameters and dose conditions. The 1.32-μm laser showed greater vaporization width and depth than the 1.06-μm laser. Both lasers controlled active bleeding. The coagulation band with the 1.32-μm laser was thinner than with the 1.06-μm laser, at nearly 3 mm. After cutting of 1- and 2-mm porcine vessels, no grossly visible bleeding was apparent. Intravascular thrombus was visible under the microscope. The length of vessel thrombosis in the experimental group was 2 mm and the diameter was 2 mm; the control group exhibited thrombi as 2.3-4.9 mm in length. Thrombosis completely blocked the blood vessels. Conclusion The 1.32-μm laser had greater vaporization capability than the 1.06-μm laser and achieved hemostasis requirements for vessels less than 2 mm in diameter.

Variation and treatment of vessels in laparoscopic right hemicolectomy.

With the introduction of complete mesocolic excision (CME) and the application of laparoscopic technique, surgery for colon cancer has become more standardized and the curative effect has improved [1]. The key points in laparoscopic right hemicolectomy are high ligation of main vessels and root dissection of lymph nodes. The wide range of variations in vascular architecture and intraoperative bleeding are common causes of prolonged surgical time, wound hemorrhage, and even transfer to the opening operation. The superior mesenteric vein (SMV) is the most important anatomical landmark in CME for the right colon, and guides all the steps of lymph node dissection. The SMV appears as a pale blue bulge on laparoscopy, which enables accurate positioning. The ileocolic vessel pedicle is relatively constant and facilitates accurate positioning. The intersection of the ileocolic vessel pedicle and the SMV is the optimal starting point in laparoscopic right hemicolectomy using a medial-to-lateral approach. A sheath with an avascular plane can be reached after opening the SMV vascular sheath, which results in less bleeding and enables vascular root and thorough lymph node dissection. The first step is to manage the ileocolic vessels. The ileocolic artery (ICA) is located anterior to the ileocolic vein (ICV) for about one-third of the incidence. The ileocolic vessels are relatively long and are easy to work with. In the vast majority of cases, the ICV drains into the SMV, and into the gastrocolic trunk (GCT) in about 2.5% of cases. The reported incidence of a right colic artery (RCA) is controversial; the RCA is absent in about 50% of cases and often crosses the SMV. The right colic vein (RCV) usually drains into the GCT, but sometimes drains directly into the SMV. The middle colic vessels have great variability and a close anatomical relationship with the pancreas, duodenum, and GCT. Moreover, the transverse colon and mesentery are long, and root positioning and processing of the middle colic vein (MCV) are relatively difficult. With the SMV and pancreas as anatomic landmarks, it is more feasible to locate the blood vessels in the neck of the pancreas. The middle colic artery (MCA) originates from the superior mesenteric artery (SMA), and the distance from the inferior border of the pancreas differs slightly in the literature, but is at the most 5cm. Identification of the MCA trunk and branches, as well as the common origin of the MCA and RCA, is of great importance for the maintaining the blood supply during surgery for primary colon cancer. The MCV mainly drains into the SMV and GCT; however, if branching variation drains into the jejunal vein, inferior mesenteric vein, or splenic vein, the effect is serious when a vessel is torn. Isolation of the GCT is the step at which bleeding will likely occur in standard right resection and is a difficult stage of the surgery. The GCT has five origins including the right gastroepiploic vein (RGV), right colic vein (RCV), accessory right colic vein (ARCV), pancreaticduodenal vein (PDV), and MCV, which can have 2, 3, or 4 branches; therefore, familiarity with variants may be helpful to avoid bleeding. Approximately 5-10% of colon cancers at the hepatic flexure have No. 6 group lymph node metastasis, and laparoscopic radical extended right hemicolectomy requires thorough dissection of No. 6 group lymph nodes and the omental arcade 10cm from the pylorus. The inferior arteriovenous vessels are a common source of bleeding, and the RGV can serve as a clue to finding the artery. The core area of laparoscopic radical extended right hemicolectomy includes the pancreatic neck, duodenum, and right gastroepiploic vessels. The difficulty lies with the standard treatment of the GCT. A medial-to-lateral approach is more in line with the principle of no-touch in tumor surgery and is applied from lower to upper, inside to outside, and left to right, for both the vessels and plane of dissection. Familiarity with vascular variation and the management of vessels in key areas are essential for successful surgery.

Recipient vessels for microsurgical flaps to the abdomen: A systematic review.

Large soft tissue defects of the abdominal wall resulting from various reasons may require free tissue transfer. A literature search of PubMed and Cochrane electronic databases was conducted to identify articles involving abdominal wall reconstruction (AWR) with microsurgical flap. Number of cases, etiology, and reconstruction site, type of microsurgical flap and recipient vessels were analyzed. Thirty-eight articles published between 1983 and 2016 reported on 149 patients undergoing free flap AWR. TFL was used in 43 patients (28.8%), LAD in 43 (28.8%), and ALT in 28 (18.7%). Conjoined ALT and TFL flap was reported in 24 patients (16.1%). The inferior epigastric artery/vein were the most commonly utilized recipient vessels (n = 43 patients). Intraperitoneal vessels were used in 18 cases, the gastroepiploic vessels being the most common (n = 9). Femoral vessels were used directly or along with a vein graft in 14 patients. AV loop or vein graft was reported in 46 patients. Great saphenous vein rerouting was used in 8 cases. DLCF vessels were used in 2 patients to support an AV loop or directly the pedicle of a microsurgical flap. The internal thoracic vessels were used in only 3 patients. The current review analyzed articles on AWR using microsurgical flaps with a special emphasis on the recipient vessels. The literature review demonstrated that there is no standard approach to repair a complex abdominal defect given the diversity of patient population. The choice of microsurgical flap and selection of recipient vessels should be tailored to the individual patient's circumstances.