Laparoscopic Gastric Devascularization Research Articles

Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension.

Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear. Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed. The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 104 /dL) than before surgery (5.5 × 104 /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices. Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.

Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak.

IntroductionMorbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy.AimTo quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD).Material and methodsWe identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days.ResultsEleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation.ConclusionsLaparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.

Prevention of recurrent bleeding from varicose veins of the esophagus and stomach among patients with decompensated liver cirrhosis

Aim. To evaluate the efficiency of laparoscopic devascularization of the esophagus and stomach with endoscopic ligation of varicose esophageal veins in the prevention of esophageal-gastric bleeding among patients with decompensated liver cirrhosis. Methods. The results of treatment of 73 patients with decompensated liver cirrhosis and high risk of bleeding were analyzed. To prevent recurrent bleeding from esophageal and gastric veins, all patients underwent endoscopic ligation at the first step of treatment. In case of inefficiency of ligation and recurrence of varicose veins of esophagus, laparoscopic devascularization of esophagus and stomach was performed. The efficiency of laparoscopic devascularization with intraoperative endoscopic ligation of varicose esophageal veins and ligation as an independent method of treatment for the prevention of upper gastrointestinal bleeding was estimated by comparison of the frequency of recurrence of esophageal and gastric bleeding and recurrence of esophageal varices according to upper endoscopy in comparison groups. Results. In 6 months, 1 and 2 years after laparoscopic devascularization of the esophagus and stomach in combination with endoscopic ligation, the risk of bleeding is less compared to endoscopic ligation as an isolated treatment method (p=0.05; p=0.052; p=0.06). Laparoscopic devascularization with ligation reduces the risk of recurrence of esophageal varices during the first year after surgery by 20% (χ2=2.61; p=0.106), in 2 years by 23% (χ2=1.75; p=0.091) compared to endoscopic ligation only. Conclusion. Patients with liver cirrhosis with decompensated hepatic failure satisfactorily postpone endovideosurgical interventions; laparoscopic gastric devascularization with the intersection of the main inflows to the esophageal varicose veins is an effective method to prevent esophageal-gastric hemorrhage among patients with decompensated liver cirrhosis after ineffective endoscopic ligation.

A successful clinical pathway protocol for minimally invasive esophagectomy.

Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay. This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15days prior to the esophagectomy. The target discharge date was postoperative day number 8. Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8days. The mean length of stay for patients without complications was 8days ± 1.2days and 12.4days ± 7.1days for patients with one or more complications (p = 0.002). The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.

Laparoscopic Gastric Devascularization Reduces Anastomotic Complications after Minimally Invasive Esophagectomy

Laparoscopic Gastric Devascularization Reduces Anastomotic Complications after Minimally Invasive Esophagectomy

Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy.

Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy. We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging. Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294min and mean blood loss was 198g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively. Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy.

Laparoscopic gastric devascularization (LGD) is an innovative method to improve gastric conduit perfusion and improve anastomotic healing following esophagectomy. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis. We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission, and complications were collected and analyzed. Thirty patients underwent LGD prior to minimally invasive Ivor Lewis esophagectomy, and 21 (70%) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9-42) days prior to esophagectomy. Median operative time was 39 (18-56) minutes, and median length of stay was 0 (0-1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93% of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17%) were readmitted within 60days of surgery: one (3%) patient with an anastomotic leak, two (7%) with pneumonia, and two (7%) with post-operative nausea and vomiting. One patient (3%) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period. LGD with delayed esophageal resection and reconstruction can be safely performed two weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3%) and absence of anastomotic strictures in this series suggest that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single-stage approaches.

Feasibility of laparoscopic gastric devascularization and splenectomy for gastric varices

Feasibility of laparoscopic gastric devascularization and splenectomy for gastric varices

An assessment of surgery for portal hypertensive patients performed at a single community hospital

The outcomes of surgery for portal hypertensive patients at a single community hospital in the last two decades were retrospectively examined. From June 1989 to March 2008, 13 of 848 (1.5%) portal hypertensive patients admitted and treated at the community hospital underwent surgery. The types of surgery performed were a distal splenorenal shunt for 2 patients, gastric devascularization and splenectomy for 8, laparoscopic gastric devascularization and splenectomy for 1, distal gastrectomy for 1, and splenectomy alone for 1. This study reviewed the postoperative records of the endoscopic findings and additional treatments, and the perioperative records. No patient had bleeding from esophagogastric varices during the 75-month mean follow-up period after surgery. Five patients had one or two series of endoscopic treatment for recurrent likely-to-bleed esophageal varices. One patient needed interventional radiology for recurrent gastric varices. No patients died due to upper gastrointestinal bleeding. The survival rates were 87.5% after 5 years and 46.9% after 10 years. Surgery for portal hypertensive patients performed at a single community hospital is still safe and effective, and has been adequately incorporated into the late treatment strategy for portal hypertensive patients.

Esophageal Replacement Following Gastric Devascularization Is Safe, Feasible, and May Decrease Anastomotic Complications

BackgroundGastric transposition is the most common reconstruction after esophagectomy. Despite technical improvements, the incidence of anastomotic complications remains high. Gastric devascularization followed by esophageal resection and reconstruction has been proposed to minimize these complications. MethodsThirty-two patients underwent minimally invasive esophagectomy, and seven high-risk patients were selected for laparoscopic gastric devascularization performed either 1 week (n = 5) or 12 weeks (n = 2) before esophageal resection. Primary outcomes included anastomotic leak and stricture. ResultsEach patient underwent successful laparoscopic devascularization and subsequent esophagectomy. Devascularization required an average of 134 minutes with minimal operative blood loss. There were no complications following gastric devascularization or directly attributable to delay. None of the delay patients developed an anastomotic leak, compared to 16% of patients after immediate reconstruction (p = 0.258). One patient (14%) developed an anastomotic stricture that required endoscopic dilatation within the first year after surgery, compared to 12% of immediate reconstruction patients (p = 0.872). ConclusionIn this series, all patients underwent successful delayed reconstruction following gastric devascularization without anastomotic leak. The absence of anastomotic leak in the delay group suggests that delayed conduit preparation can be accomplished safely while potentially reducing the morbidity associated with esophagectomy, but larger prospective studies are required to prove this definitively.

Laparoscopic partial gastric transection and devascularization in order to enhance its flow

BackgroundEsophagogastric fistula following an esophagectomy for cancer is very common. One of the most important factors that leads to its development is gastric isquemia. We hypothesize that laparoscopic gastric devascularization and partial transection is a safe operation that will enhance the vascular flow of the fundus of the stomach.MethodOur study included eight pigs. Each animal had two operations. In the first one, a laparoscopic gastric devascularization and mobilization took place. Vascular flow was measured previous to the procedure and immediately after it with a laser doppler (endoscopic probe). After three weeks, a second operation took place. We re-measured the vascular flow and sent a sample of gastric fundus for histopathologic evaluation.ResultsThe gastric fundus showed signs of neovascularization after both macroscopic and microscopic evaluation. These findings correlated with laser doppler measurements.ConclusionLaparoscopic gastric devascularization and partial transection is a safe procedure that increases the vascular flow of the stomach in a three week period. This finding can have a positive impact in terms of decreasing fistula formation.

Effectiveness of laparoscopic gastric devascularization and splenectomy in the management of refractory esophagogastric varices with liver cirrhosis.

Effectiveness of laparoscopic gastric devascularization and splenectomy in the management of refractory esophagogastric varices with liver cirrhosis.

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

Background: The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices. Study Design: Laparoscopic gastric devascularization and splenectomy (Hassab’s operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n = 4) and recurrent rebleeding gastric varices (n = 6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints. Results: The duration of the operation ranged from 200 to 400 minutes (mean ± standard deviation; 287.5 ± 66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5 ± 507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0 ± 126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 × 10 4/μL (average, 4.5 ± 2.7 × 10 4 μL) and the postoperative count was from 5.9 to 36.0 × 10 4/μL (average, 21.7 ± 11.5 × 10 4 μL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8 ± 4.1 months (average, 8 to 20 months). Conclusions: The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.