Retrosternal Gastric Tube Reconstruction Research Articles

Persistent bilateral pneumothorax after robotic-assisted inguinal hernia repair: possible relevance to recent esophageal cancer surgery — a case report

BackgroundPostoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. There has been no report describing pneumothorax that persisted for a week or more after laparoscopic surgery. Herein, we report a case of bilateral pneumothorax after laparoscopic surgery, which appears to have occurred by a different mechanism than previously described.Case presentationA 65-year-old male, with a past history of esophagectomy and retrosternal gastric tube reconstruction 4 months earlier, underwent a robotic-assisted inguinal hernia repair. Postoperative chest x-rays revealed the development of bilateral pneumothorax, which became worse on postoperative day (POD) 1 and took more than 9 days to resolve spontaneously. We assumed that intra-abdominal gas replaced by the air after pneumoperitoneum might have migrated into thoracic cavities through an opened esophageal hiatus or along the retrosternal route.ConclusionsLaparoscopic surgery after radical esophagectomy may be associated with an increased risk of postoperative pneumothorax.

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

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

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

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

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

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

Left Hemihepatectomy for Hepatocellular Carcinoma Following Esophagectomy with Retrosternal Gastric Tube Reconstruction for Esophageal Cancer.

Approximately 4% of patients with esophageal cancer develop a second primary malignancy in the upper gastrointestinal trunk. However, hepatectomy following esophagectomy for esophageal cancer has rarely been reported. We report the case of a 70-year-old man who underwent an esophagectomy for esophageal cancer with retrosternal gastric tube reconstruction. Nine years later, he developed hepatocellular carcinoma with tumor thrombus involving the left portal vein, and was successfully treated with left hemihepatectomy. Special attention should be paid to avoiding incidental injury of the gastric tube as well as the right gastroepiploic artery during the hepatectomy.

The sterno-tracheal distance is an important factor of anastomotic leakage of retrosternal gastric tube reconstruction after esophagectomy.

Anastomotic leakage (AL) is a serious complication after esophagectomy. The retrosternal (RS) route has been selected majorly to reduce reflux and related pneumonia and considering mediastinal recurrences. AL has been developed more in RS than posterior mediastinal (PM) route reconstruction. Therefore, we suspected the sterno-tracheal distance (STD) might be related to AL and started the selection according to the STD from 2009. A total of 221 patients who underwent a subtotal esophagectomy with gastric tube reconstruction during January 2004-April 2017 were investigated. The patients were classified into the 'after STD selection' (A; n = 144) group and the 'before STD selection' (B, n = 77) group. The incidences of and the risk factors for AL between the two groups were compared. The incidence of AL was high in the B group (18.2%), and 78.6% of the patients who developed AL were treated with RS route reconstruction. The median STDs of the patients with AL and no AL were 10.3mm and 14.5mm, respectively (p = 0.001). These results demonstrated that the STD was a risk factor for AL in the RS route. Based on these results, 13mm was set as the cutoff value. After STD selection, the median STD increased from 14.0 to 17.3mm (p = 0.001), and the incidence of AL decreased significantly from 26.2 to 11.1% in the RS route (p = 0.037). The STD was the independent risk factor for AL in the RS route. RS route reconstruction should be avoided for the patients with STD < 13mm.

A Case of Gastric Tube Constriction following Subtotal Esophagectomy with Retrosternal Gastric Tube Reconstruction Resolved by Partial Sternal Resection

A Case of Gastric Tube Constriction following Subtotal Esophagectomy with Retrosternal Gastric Tube Reconstruction Resolved by Partial Sternal Resection

Comparison of Feeding Jejunostomy via Gastric Tube Versus Jejunum After Esophageal Cancer Surgery

Jejunostomy is an essential route for nutritional support after esophageal cancer surgery. However, catheter-related complications may occur. This study compared the complications of feeding jejunostomy between gastric tube and jejunum after esophageal cancer surgery. The records of 215 patients with esophageal cancer who underwent radical esophagectomy with retrosternal gastric tube reconstruction between January 2010 and November 2016 were examined. One hundred and thirty-three patients underwent feeding jejunostomy via gastric tube and 82 patients underwent the procedure via the jejunum, and their records were reviewed for catheter-related complications. Catheter-related complications occurred in five patients in the gastric tube group and 12 in the jejunum group (3.8% vs. 14.6%, p=0.005). Mechanical bowel obstruction requiring surgical therapy occurred in three patients in the jejunum group, but in none in the gastric tube group (p=0.026). Feeding jejunostomy reconstruction via gastric tube appears to be a safe and useful procedure.

Entral feeding tube insertion after esophagectomy: Technique via transgastric conduit or transduodenal.

210 Background: We always used early enteral feeding after esophagectomy as perioperative management. The common procedure for feeding tube insertion is jejunostomy, but sometimes complication such as internal hernia was occurred. In case of retrosternal gastric tube reconstruction, we usually inserted feeding tube through gastric conduit. But in case of posterior mediastinal gastric tube reconstruction, this procedure was not available because of the distance between abdominal wall and gastric tube. So we have developed the new procedure for feeding tube insertion using the mobilized round ligament of liver. Methods: The aims of the study is to clarify the safety of these procedures. In case of retrosternal reconstruction, we usually inserted feeding tube from prepylorus of gastric conduit, and feeding tube was delivered through pyloric ring to 3rd portion of duodenum(Procedure A). Insertion point of the tube was always close to abdominal wall, and easy to be guided to extra-abdomen. On the other hand, in case of posterior reconstruction, we used the new procedure as below(Procedure B). At first, the round ligament of liver was cut at the liver edge. Next, feeding tube was inserted 15~20cm from anterior wall of 2nd portion of duodenum with Witzel suture fixation. After that, feeding tube was led to outside of the abdominal wall through in the mobilized round ligament. The cut edge of round ligament was fixed to the duodenum wall with 4-point suture at tube insertion point, and finally feeding tube completely surrounded by round ligament without direct exposure to the abdominal cavity. And to prevent internal hernia, the space between abdominal wall and mobilized round ligament was covered by omental fat. Results: From January 2012 to December 2014, 126 cases were inserted by procedure A, and from June 2015 to February 2016, 35 cases were done by procedure B. There was no trouble derived from the feeding tube insertion such as intra-operative bleeding, leakage of digestive juice, infectious complication, ileus, and there was no trouble in removal at outpatients in both procedures. Conclusions: Both procedures were safe, so we can manage the feeding tube insertion route by the reconstruction route after esophagectomy.

食道癌術後に発症した急性大動脈解離に対する1手術例

食道癌術後に発症した急性大動脈解離に対する1手術例

Surgical repair of an acute Stanford type A aortic dissection in a patient with a retrosternal gastric tube

Cardiovascular surgery in patients with a retrosternal gastric tube (RGT) remains rare despite improvements in the prognosis of oesophageal cancer. A 75-year old woman with a history of total thoracic oesophagectomy with RGT reconstruction required emergency aortic arch replacement for an acute Stanford type A aortic dissection. We opted for a median sternotomy approach involving complete dissection of the RGT from surrounding tissues and retraction for surgical access to the dissection. Enhanced computed tomography was useful for the diagnosis and planning of the emergency surgery.

Feeding Tube Insertion Through the Round Ligament of Liver: A Safe Approach to Placing a Feeding Tube for Retrosternal Gastric Tube Reconstruction after Esophagectomy

Watanabe, Masayuki MD, PhD, FACS; Etoh, Kojiro MD; Nagai, Yohei MD; Baba, Yoshifumi MD, PhD; Iwatsuki, Masaaki MD, PhD; Ishimoto, Takatsugu MD, PhD; Sakamoto, Yasuo MD, PhD; Miyamoto, Yuji MD, PhD; Yoshida, Naoya MD, PhD; Baba, Hideo MD, PhD, FACS* Author Information

Endovascular Aortic Arch Reconstruction Using In Situ Stent-Graft Fenestration in the Brachiocephalic Artery

A patient who had previously undergone retrosternal gastric tube reconstruction for esophageal cancer presented with an aortic arch aneurysm. The patient was treated with endovascular stent-graft placement without median sternotomy, followed by revascularization of the brachiocephalic trunk using percutaneous in situ graft fenestration. A 9-month follow-up examination revealed marked regression of the aneurysm with patency of the stent-graft, without any complications. This in situ fenestration technique may extend the limits of thoracic endovascular therapy for patients who are unsuitable for sternotomy or aortic side-clamping.

Aortic Valve Replacement in a Patient with a Retrosternal Gastric Tube

A 65-year-old male with a history of a total thoracic esophagectomy with a retrosternal gastric tube reconstruction required aortic valve replacement for aortic valve stenosis due to a bicuspid aortic valve. Preoperative multidetector computed tomography demonstrated that the gastric tube occupied the retrosternal space and the gastroepiploic artery was located on the left side of the gastric tube. Aortic valve replacement was performed through a median sternotomy approach. Blunt dissection on the anterior and right side of the gastric tube was performed without injury, and we could then perform cardiac surgery with the standard surgical view.

胸骨後経路胃管再建による食道癌手術後の僧帽弁輪石灰化を伴う僧帽弁逆流，三尖弁逆流症例に対する右傍胸骨アプローチによる１治験例

食道癌切除術，胃管再建を後胸骨経路で行う方法は吻合箇所が少なく，縫合不全や胃管における潰瘍・癌の発生への対処の容易さ，美容上の問題などから胸骨前経路や後縦隔経路で行う方法よりも本邦では一般的となっている．この後胸骨胃管再建を行った後の心臓手術を胸骨正中切開で行うには胃管損傷，縦隔炎のリスクがある．僧帽弁後尖弁輪の石灰化を伴う僧帽弁逆流，三尖弁逆流の症例に対して右傍胸骨アプローチで僧帽弁人工弁置換術，三尖弁輪形成術を行った．術野が深く，手術操作の自由度が小さかったが馬心膜をcollarとして後尖側の弁輪部を補強した人工弁置換の遂行が可能であった．複雑病変であったこと，経食道心エコーを使用できず逆流の評価が困難であることなどからの理由で僧帽弁形成術を選択しなかった．右傍胸骨アプローチを用いたため，胃管損傷のリスクはほぼ皆無であり経口摂取を速やかに再開することができた．肋骨を複数切除した胸壁欠損部の脆弱性が問題となるがcomposite meshを補填することで十分な強度が得られた．

EARLY SMALL CELL CARCINOMA OF THE ESOPHAGUS ASSOCIATED WITH WERNICKE-KORSAKOFF SYNDROME -REPORT OF A CASE-

A case of early small cell carcinoma of the esophagus which was detected during treatment for Wernicke-Korsakoff syndrome due to vitamin B1 deficiency and was treated by operation with adjuvant chemotherapy, is reported. A 53-year-old man, who had been receiving therapy for Wernicke-Korsakoff syndrome at the department of internal medicine in our hospital, was point out having 2+O-IIc type of esophageal cancer on upper gastrointestinal series for screening purpose. His previous medical history was unknown. The patient was transferred to the department, and underwent a right thoracolaparotomic subtotal esophagectomy, retrosternal gastric tube reconstruction, and R-II. Histopathologically, the 0-Ilc type lesion was moderately differentiated squamous cell carcinoma with the invasion depth of mm3, and the 2 type lesion was composed of small cell type of poorly differentiated carcinoma with ythe invasion depth of sm3. Otherwise, n (-), lyl, and v2 were rated. After the operation adjuvant chemotherapy with CDDP and 5 FU was conducted. There has been no sign of recurrence, as of 11 months after the operation.