Posterior Route Research Articles

An individual's physique is associated with the length of the reconstruction route via the retrosternal approach.

We hypothesized that an individual's physique is related to reconstruction length, as organs reconstructed via the retrosternal route are curved toward the ventral side. This study aimed to determine factors contributing to the reconstruction length of the retrosternal route. Fifty patients underwent subtotal esophagectomy with esophagogastric reconstruction via the posterior mediastinal route between 2010 and 2014; the esophagus-stomach and posterior mediastinal route lengths were measured to evaluate whether they could be approximated. Forty patients underwent reconstruction via the retrosternal route between 2015 and 2020; the esophagus-stomach and retrosternal route lengths were compared, and contributing factors were analyzed. Each length was measured perioperatively using three-dimensional enhanced computed tomography images. The associated factors obtained included age, sex, height, body weight, body mass index, thickness and height of the thorax, depth of the thoracic inlet space, thoracic curve, left hepatic lobe volume, and the thickness and height of the liver. The length of the esophagus-stomach could approximate that of the posterior mediastinal route [posterior mediastinal-esophagus-stomach; 0.04 (-0.5-0.6) cm, p = 0.77]. Using three-dimensional enhanced computed tomography images, the lengths of the esophagus-stomach and retrosternal routes were comparable, despite variability [retrosternal-esophagus-stomach; 0.72 (-0.1-1.8) cm, p = 0.095]. Analyzing factors associated with the length revealed a positive correlation of body weight, body mass index, and thickness of the thorax with the difference. A higher body mass index (OR = 1.7, 95% CI 1.1-2.8, p = 0.007) was associated with a longer retrosternal route in the multivariate analysis. An individual's physique is associated with the reconstruction length; particularly, the length of the retrosternal route was longer in patients with a high body mass index.

Evaluation of surgical characteristics and clinical outcome of 11 patients with thoracic discectomy through transfacet approach

Background: In thoracal disc herniation (TDH) requiring surgery, the size, level, anatomic location, and calcification of the disc are extremely important in the selection of the technique to be applied. Since the thoracic region does not allow spinal cord manipulation, the surgery is difficult and requires experience. A consecutive series of patients who underwent thoracic discectomy through a posterior transfacet approach is presented in this study. Methods: Eleven patients (6 men, and 5 women) underwent surgery at 12 disc levels. The mean age was 53.54 years (range 28-72 years). Patients presented with myelopathy (n = 8, 73%), radiculopathy (n = 7, 64%), back pain (n =10, 91%), and urinary dysfunction (n = 6, 55%). Seven (58%) lateral, 3 (25%) calcified, and 4 (33%) large disc herniations were revealed by preoperative imaging. The mean follow-up period was 21.02 ± 8.04 months (range 6 – 43 months). Results: A posterior transfacet approach was used for all eleven patients with TDH. Thoracic discectomy was performed at T11- 12 (36%) level for 4 patients, and equally at T10- 11 (36%) level for the other 4 patients. A bilateral approach with laminotomy was performed in one patient, and a two-level discectomy was performed in another patient. Unilateral partial laminectomy was added for 3 patients. The average operating time was 146.85 minutes (range 125-220 minutes). The average hospital stay was 4.2 days (range, 2- 13 days) while no neurological functional deterioration was observed in any of the patients after surgery. Postoperative 1-month and 6-month ODI scores were found significantly different from preoperative ODI scores in all patients. Conclusions: Thoracal discectomy through the posterior transfacet approach route is a safe and effective technique to achieve adequate decompression without requiring instrumented fusion.

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.

343. THE RISK FACTORS OF HIATAL HERNIA IN ESOPHAGEAL CANCER PATIENTS WHO RECEIVED GASTRIC INTERPOSITION THROUGH POSTERIOR MEDIASTINAL ROUTE

Abstract Hiatal hernia (HH) after esophagectomy is becoming more relevant due to improvement in survival. The aims of this study were to define the incidence, risk factors of HH in patients who underwent esophagectomy and reconstructed with gastric tube via posterior mediastinal route. We performed a monocentric retrospective study on 510 patients with esophageal cancer who underwent esophagectomy and reconstructed with the gastric substitute via posterior mediastinal route from 2007 to 2019. All postoperative computer tomography images were re-reviewed by two radiologists independently. The incidence of HH was estimated using Kalbfleisch and Prentice method and risk factors of HH were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. A total of 27 developed HH with the two-year cumulative incidence of 5.3%. The median time to diagnosis was 297 days. HH were symptomatic in 14 patients (52%) in whom five required emergent repair. Among the 22 patients who were treated non-operatively, progression of HH was found in 9. In the multivariable analysis, the risk factors for HH were: laparoscopic gastric tube harvest (HR = 5.756[1.07 ~ 31.2], p = 0.042) and the use of preoperative therapy (HR = 2.714[1.03 ~ 7.14], p = 0.043) were identified as independent factors associated with increased risk of HH. HH represents a relevant surgical complication after esophagectomy and reconstructed with the gastric substitute via posterior mediastinal route. Especially in those who received preoperative therapy and using laparoscopic approach.

647. A CASE OF ACUTE GASTRIC TUBE ULCER BLEEDING SAVED BY EMERGENCY SURGERY

Abstract Gastric tube ulcer is recognized as one of the complications after esophageal cancer surgery. When a ulcer bleeds, or penetrates to the pericardial space, or perforates, it often follows a fatal course due to its anatomical position and the complexity of surgical treatment. We report a case of persistent bleeding from a gastric tube ulcer after esophageal cancer operation, which was unable to treat endoscopically. The case was a 67-year-old man. Thoracoscopic subtotal esophagectomy and posterior mediastinal route subtotal gastric reconstruction were performed for middle thoracic esophageal cancer. His fifth-year regular endoscopy revealed a gastric tube ulcer. As a cause of myalgia, the patient was prescribed NSAIDs every day by a nearby doctor. Initially, no bleeding was observed, and discontinuance of NSAIDs and conservative treatment with PPI was continued. However, five months later, sudden hematemesis was observed at night, and he was transferred to a nearby doctor. Emergency endoscopy revealed gastric tube ulcer bleeding. And he was transferred to our hospital in an emergency. However, two days later, hematemesis and persistent ulcer hemorrhage were observed. Due to the difficulty of cauterizing to heartbeat, emergency surgery was performed. The first attempt was made to approach by a posterior mediastinal route, but it was difficult to confirm the ulcer and it was difficult to control bleeding without compression. Adding the thoracotomy, the ulcer was confirmed under direct vision. An ulcer defect was about 5 cm, bleeding was from the ulcer margin. Barbed suture closure and the omental patch were performed. The postoperative course was uneventful and discharged from the hospital 21 days after the operation. We experienced a rare case of acute hemorrhagic gastric tube ulcer that was difficult to treat conservatively and was saved by emergency surgery. After reconstruction of esophageal cancer, there are complicated situations such as the route of the elevated gastric tube, the position of the ulcer, and the risk of perforation to the pericardial space. Prompt and accurate medical care is required.

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.

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.

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.

529. ANALYSES OF CLINICAL FACTORS AFFECTING POSTOPERATIVE SYMPTOMS INCLUDING BODY WEIGHT LOSS, ORAL INTAKE, AND REFLUX AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Some patients complain of serious postoperative digestive symptoms after esophagectomy. However, it has not been clear what clinical factors are related to these symptoms. In this study, we investigate the relationships between postoperative digestive symptoms (body weight loss, subjective oral intake, and reflux) and clinical factors. Of 155 patients who underwent esophagectomy at our department from April 2019 to July 2021, 75 patients were eligible because they could be followed up at our outpatient clinic without relapse. Postoperative symptoms including body weight loss, oral intake ≥70%, and reflux were asked. Regarding clinical factors, age, sex, route of reconstruction, the width and the location of the gastric tube in CT images, and the location of pylorus ring in CT images were investigated retrospectively. The median body weight loss was 10.5%. Oral intake ≥70% was found in 37/61. 24/50 patients complained of reflux. The mean body weight loss was 6.2% in the intrathoracic anastomosis, 10.5% in the posterior mediastinal route, and 12.6% in the retrosternal route (p=0.04). Oral intake ≥70% was found in 20/29 of the wide gastric tube group and 16/31 of the narrow gastric tube group (p=0.197). The group with oral intake ≥70% was likely to be younger (p<0.01), and male is likely to have oral intake ≥70% (p=0.193). Regarding reflux, there were no difference in clinical factors. Although this is a retrospective study and biases in each group are found, body weight loss is less found in the intrathorax anastomosis and in the duodenostomy group via a retrosternal route. Oral intake is likely to be more in younger patients, in male, and in patients with wider gastric tube. On the other hand, no clinical factors were found related to reflux.

303. A NOVEL ‘WATERFALL METHOD’ OF FILLING THE POSTERIOR MEDIASTINAL CAVITY AFTER ESOPHAGECTOMY USING OMENTAL FLAP IN RETROSTERNAL GASTRIC TUBE RECONSTRUCTION

Abstract Post-esophagectomized mediastinal dead space can cause not only mediastinal abscess in R2 resection, but also airway trouble in salvage surgery or combined resection of the airway system due to intra-thoracic great pressure fluctuations. Therefore, dead space filling is critical to prevent them. Dead space is filled with an omentum pulled up in posterior mediastinal route along with the gastric tube. However, it causes delayed gastric empty, considerably decreasing the patient’s quality of life (QOL). We have developed a new technique to fill the dead space by dropping the omentum from the anterior to the posterior mediastinum after lifting it in the retrosternal route along with the gastric tube, and named it the waterfall method. When creating a gastric tube, the omentum is taken as many as possible, and is fixed to pull-up thread so that it is about 15 cm below the tip of the gastric tube. After lifting the gastric tube to the neck, pull the omental flap down through a small incision in the anterior mediastinal pleura and fill the mediastinal dead space. Of 630 esophageal cancer patients who underwent surgery from January 2012 to March 2022, this new technique was adopted to 20 patients (mean age: 65Y, male/female: 16/4). The reason for adaptation was R2 resection in 7, salvage surgery in 4, combined resection of the airway system in 8 and other in 1. All patients underwent chemoradiation with more than 50 Gy or triplet chemotherapy preoperatively. Minor anastomotic leakage was observed in 2 and pneumonia and pneumothorax in 3 and 3, respectively. But no development of mediastinal abscess or airway fistula was observed, and no patient complained delayed gastric empty. Our new technique to fill the post-esophagectomized mediastinal dead space by dropping an omental flap from the anterior to the posterior mediastinum was considered useful, safe and feasible to prevent the development of mediastinal abscess or airway fistula. Since there is no symptom of delayed gastric empty, it is considered to be one of the useful surgical procedures that can maintain the patient’s QOL as well as prevent postoperative complications.

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.

Surgical and Electrical Anatomy of the Inter-Nodal and Intra-Atrial Conduction System in the Heart.

An anatomical understanding of the atrial myocardium is crucial for surgeons and interventionists who treat atrial arrhythmias. We reviewed the anatomy of the inter-nodal and intra-atrial conduction systems. The anterior inter-nodal route (#1) arises from the sinus node and runs through the ventral wall of the atrial chambers. The major branch of route #1 approaches the atrioventricular node from the anterior aspect. Other branches of route #1 are Bachmann’s bundle and a vestibular branch around the tricuspid valve. The middle inter-nodal route (#2) begins with a broad span of fibers at the sinus venarum and extends to the superior limbus of the oval fossa. The major branch of route #2 joins with the branch of route #1 at the anterior part of the atrioventricular node. The posterior inter-nodal route (#3) is at the terminal crest and gives rise to many branches at the pectinate muscles of the right atrium and then approaches the posterior atrioventricular node after joining with the vestibular branch of route #1. The branches of the left part of Bachmann’s bundle and the branches of the second inter-nodal route form a thin myocardial network at the posterior wall of the left atrium. These anatomical structures could be categorized into major routes and side branches. There are 9 or more anatomical circles in the atrial chambers that could be structural sites for macro re-entry. The implications of normal and abnormal structures of the myocardium for the pathogenesis and treatment of atrial arrhythmias are discussed.

Huge esophageal gastrointestinal stromal tumor successfully resected under mediastino-laparoscopic transhiatal esophagectomy: a case report

BackgroundEsophageal gastrointestinal stromal tumors (E-GISTs) are often diagnosed early due to complaints such as dysphagia and are rarely found to be huge in size. Here, we report the treatment of a case of huge E-GIST successfully resected by minimally invasive surgery after neoadjuvant imatinib therapy.Case presentationAn 86-year-old male patient with a 3-month history of dysphagia was referred to our hospital because of a suspected mediastinal tumor on chest X-ray. The chest computed tomography scan revealed a huge solid tumor, of about 100 mm in diameter, protruding into the left thoracic cavity. Histopathological examination results of fine-needle aspiration biopsy under endoscopic ultrasonography revealed a c-kit and CD34-positive esophageal gastrointestinal stromal tumor. The patient received neoadjuvant therapy with imatinib (400 mg/day) to reduce the size of the tumor and prevent rupture during resection. After 28 days of oral administration of imatinib, the tumor size decreased. However, the patient refused to continue treatment with imatinib and therefore underwent mediastino-laparoscopic transhiatal esophagectomy. We successfully resected the tumor completely with mediastino-laparoscopic surgical techniques. Esophageal reconstruction was performed using a gastric tube in the posterior sternal route. After an uneventful postoperative course, the patient was discharged postoperative day 14. Immunohistochemical findings of the resected specimen showed that the tumor cells were positive for c-kit, DOG-1 and CD34 and negative for smooth muscle actin and S100.ConclusionsHybrid surgical procedure utilizing mediastino-laparoscopy might be useful for high-risk patient with esophageal tumors.

Neural glymphatic system: Clinical implications and potential importance of melatonin

The central nervous system was thought to lack a lymphatic drainage until the recent discovery of the neural glymphatic system. This highly specialized waste disposal network includes classical lymphatic vessels in the dura that absorb fluid and metabolic by-products and debris from the underlying cerebrospinal fluid (CSF) in the subarachnoid space. The subarachnoid space is continuous with the Virchow-Robin peri-arterial and peri-vascular spaces which surround the arteries and veins that penetrate into the neural tissue, respectively. The dural lymphatic vessels exit the cranial vault via an anterior and a posterior route and eventually drain into the deep cervical lymph nodes. Aided by the presence of aquaporin 4 on the perivascular endfeet of astrocytes, nutrients and other molecules enter the brain from peri-arterial spaces and form interstitial fluid (ISF) that baths neurons and glia before being released into peri-venous spaces. Melatonin, a pineal-derived secretory product which is in much higher concentration in the CSF than in the blood, is believed to follow this route and to clear waste products such as amyloid-β from the interstitial space. The clearance of amyloid-β reportedly occurs especially during slow wave sleep which happens concurrently with highest CSF levels of melatonin. Experimentally, exogenously-administered melatonin defers amyloid-β buildup in the brain of animals and causes its accumulation in the cervical lymph nodes. Clinically, with increased age CSF melatonin levels decrease markedly, co-incident with neurodegeneration and dementia. Collectively, these findings suggest a potential association between the loss of melatonin, decreased glymphatic drainage and neurocognitive decline in the elderly.

Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review

BackgroundThe development of esophago-bronchial fistula after esophagectomy and reconstruction using a posterior mediastinal gastric tube remains a rare complication associated with a high rate of mortality.Case presentationA 63-year-old man with esophageal cancer underwent a thoracoscopic esophagectomy with two-field lymph node dissection and reconstruction via a gastric tube through the posterior mediastinal route. Postoperatively, the patient developed extensive pyothorax in the right lung due to port site bleeding and hematoma infection. Four months after surgery, he developed an esophago-left bronchial fistula due to ischemia of the cervical esophagus and severe reflux esophagitis at the site of the anastomosis. Because of respiratory failure due to the esophago-bronchial fistula and the history of extensive right pyothorax, right thoracotomy and left one-lung ventilation were thought to be impossible, so we decided to perform the surgery in three-step systematically. First, we inserted a decompression catheter and feeding tube into the gastric tube as a gastrostomy and expected neovascularization to develop from the wall of the gastric tube through the anastomosis after this procedure. Second, 14 months after esophagectomy, we constructed an esophagostomy after confirming blood flow in the distal side of the cervical esophagus via gastric tube using intraoperative indocyanine green-guided blood flow evaluation. In the final step, we closed the esophagostomy and performed a cervical esophago-jejunal anastomosis to restore esophageal continuity using a pedicle jejunum in a Roux-en-Y anastomosis via a subcutaneous route.ConclusionThis three-step operation can be an effective procedure for patients with esophago-left bronchial fistula after esophagectomy, especially those with respiratory failure and difficulty in undergoing right thoracotomy with left one-lung ventilation.

Surgical outcomes of two different reconstruction routes for esophagectomy in esophageal cancer patients: a meta-analysis.

To evaluate the effects of two different reconstruction routes (the posterior mediastinal route (PR) and the retrosternal route (RR)) on the surgical outcomes of patients after esophagectomy for esophageal carcinoma. PubMed, Embase, Web of Science and Scopus were searched from database inception to March 2021. Randomized controlled trials (RCTs) and case-control trials on the surgical outcomes of patients undergoing esophagectomy via one of the two routes were included. RevMan 5.3 software was used for the meta-analysis. In total, 19 studies were included, 8 were RCTs and 11 were case-control studies. The meta-analysis showed that among the case-control trials, the PR had reduced rates of anastomotic leakage [odds ratio (OR) = 0.56, 95% confidence interval (CI) (0.43, 0.74), P < 0.01]. In addition, it had reduced rates of anastomotic stenosis [OR = 0.42, 95% CI (0.30, 0.59), P < 0.01] and pulmonary complications [OR = 0.63, 95% CI (0.47, 0.84), P < 0.01]. However, there was no significant difference in cardiac complications [RCTs, relative risk (RR) = 0.57, 95% CI (0.29, 1.11), P = 0.10; case-control trials, OR = 1.06, 95% CI (0.70, 1.62), P = 0.78] or postoperative mortality [RCTs, RR = 0.47, 95% CI (0.19, 1.16), P = 0.10; case-control trials, OR = 0.68, 95% CI (0.32, 1.44), P = 0.31]. Compared with the RR, the PR had reduced rates of anastomotic leakage, anastomotic stenosis and pulmonary complications.

383 LAPAROSCOPIC CREATION OF RETROSTERNAL ROUTE FOR GASTRIC CONDUIT RECONSTRUCTION; SAFE AND FEASIBLE PROCEDURE

Abstract Reconstruction routes after esophagectomy include posterior mediastinal, retrosternal, and subcutaneous route. We have performed posterior mediastinal reconstruction, but this route has higher risks of gastro-tracheal fistula and hiatal hernia. To avoid these complications, now we take the retrosternal route as our first choice by creating the route laparoscopically before pulling-up gastric conduit. We report the successful and safe procedure. Methods We performed laparoscopic creation of retrosternal route in 13 thoracoscopic/robot-assisted minimally invasive esophagectomies since August 2019. In practice, a peritoneal incision at the dorsal side of the xiphoid process is started. Then, via 12 mm port on the surgeon's right hand inserted slightly to the right and cranial side of the umbilical camera port, we dissect loose connective tissues from the caudal side to the cranial side behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route and pleural injury rate during the procedure was examined. Results Thirteen cases were divided into two groups as early period group (seven cases) and later period group (six cases) respectively. The time required for route creation was 31.3 minutes(average) in the early period group, and 16.7 minutes in the later period group. There is tendency towards faster in later period group than in earlier one. The overall pleural injury rate was 15% (2 of 13 cases). Although it was difficult to determine the amount of bleeding, it was visually observed that the bleeding during the route creation was lower in the later period group than in the early period group. Conclusion The entire laparoscopic procedure to create retrosternal route makes it easier to observe and preserve the pleura and internal thoracic vessels compared to blind blunt dissection. As a conclusion, laparoscopic creation of retrosternal route for gastric conduit reconstruction is safe and feasible with good learning curve. Video https://www.dropbox.com/sh/p0wc3x46n33jp23/AADwiWHYIEUNUX6qZsERVIOga?dl=0.

594 HAND-SEWN CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS AFTER ESOPHAGECTOMY

Abstract Successful anastomosis is essential in esophagogastrectomy. Staplers are more popularly applied for the anastomosis. However, a hand-sewn anastomosis is a basic and cost-effective method. Herein, we introduce our technical tips of all hand-sewn cervical esophagogastric anastomosis. Methods Step 1: A 6 cm gastric tube is created and pulled up through the posterior mediastinal route. Step 2: A single layer Gambee sutures are used to approximate the cervical esophagus and the posterior wall of the gastric tube in end-to-side fashion. Step 3: The redundant part in the gastric tube apex is removed. Results We analyzed 199 consecutive patients who underwent this anastomosis in our institute from 2004 to 2019. There was no postoperative mortality. Anastomotic leak (Clavien-Dindo classification; Grade ≥ II) rate was 2.5%. Anastomotic stricture which required balloon dilation was 3.5%. Conclusion The anastomotic complication rates in the hand-sewn anastomosis were comparable to those of the mechanical stapled anastomosis in the previous reports. Video https://www.dropbox.com/s/sxnxs4962aj5n5k/anastomosis.mp4?dl=0.

436 PRONE THORACOSCOPIC ESOPHAGECTOMY FOR PATIENTS WITH LOW PULMONARY FUNCTION

Abstract Thoracoscopic esophagectomy in the prone position (TEP) for esophageal cancer is reported to have superiority in preserving postoperative respiratory function and reducing postoperative respiratory complications. In Japan, the majority of patients with esophageal cancer are smokers and have obstructive ventilation disorders. But, the feasibirity and safety of TEP for patients with low respiratory function is unclear. Objectives To clarify the feasibirity and safety of TEP for esophageal cancer patients with obstructive respiratory function. Methods The 95 patients with obstructive respiratory disorder who underwent TEP and gastric tube reconstruction via posterior mediastinal route for esophageal cancer from January 2016 to April 2019 were divided into the two groups, low respiratory function (LRF) group and the control group. Short-term outcomes were compared between two groups. Results The control group was 73 cases, and the LRF group was 22 cases. Propensity score matching using age, gender, cT, and cN as covariates was used to identify matched patients (22 per group) in both groups. There were no differences in operation time of overall and intrathoracic part, or blood loss in each group. In the postoperative complications, pneumonia (13.6% vs. 9.1%), recurrent laryngeal palsy (18.2% vs. 22.7%), anastomotic leakage (13.6% vs. 13.6%) and hospital stay (36.3 days vs 27.5 days) were no differences in both groups. Conclusion TEP can be feasible and safe for the patients with obstructive ventilation disorder and low respiratory function.

469 ASSESSMENT OF PERFUSION OF GASTRIC CONDUIT AND PROXIMAL ESOPHAGEAL STUMP BY INDOCYANINE GREEN FLUORESCENCE IMAGING IN PATIENTS UNDERGOING ESOPHAGECTOMY

Abstract Post esophagectomy anastomotic leakage and stricture are crucial factors in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complications. This prospective study assesses the utility of intraoperative indocyanine green (ICG) fluorescence imaging to determine gastric conduit vascularity in patients undergoing esophagectomy. Methods Thirteen consecutive patients who were undergoing esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019, were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic assisted esophagectomy. Reconstruction was done by gastric pull up via posterior mediastinal route. Vascularity of gastric conduit was assessed by the near-infrared camera using ICG. Results On visual assessment of perfusion at the tip of gastric conduit, it was dusky in 11 patients, pink in two. Fuorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, needing revision. In one patient visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit’s tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 seconds (10 to 23 seconds). Conclusion Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is more objective and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. It could complement the visual inspection to decide the site of anastomosis.