Seromuscular Flap Research Articles

Efficacy and feasibility of tunnel esophagogastrostomy to perform proximal gastrectomy

Objective: To analyze the efficacy and feasibility of performing a new surgical procedure, tunnel esophagogastrostomy, to perform proximal gastrectomy. Methods: The study cohort comprised 10 consecutive patients who had undergone esophagogastrostomy by the tunnel technique in Jiangsu Cancer Hospital between October 2019 and July 2022. All patients were male. Their average age was (64.2±8.1) years and body mass index (25.5±3.2) kg/m2. Nine had upper gastric body adenocarcinoma, the remaining one having signet ring cell carcinoma. TNM staging of the tumors showed that seven were Stage IA, one Stage IB, one Stage IIA, and one Stage IIIA. Briefly, tunnel esophagogastrostomy is performed as follows: After performing a proximal gastrectomy, a rectangular seromuscular flap (3.0 cm × 3.5 cm) is created. The posterior esophageal wall is sutured to the gastric wall at the orad end of the seromuscular flap 5 cm from the stump with three to four stitches. Next, the stump of the esophagus is opened, the posterior esophageal wall is sutured to the gastric mucosa and submucosa, and the anterior esophageal wall is sutured to the full layer of the stomach. Finally, the caudad end of the seromuscular flap is closed. Data on surgical safety, postoperative morbidity, and postoperative reflux esophagitis were analyzed. All enrolled patients completed endoscopic follow-up 1 year and 2 years after surgery. Results: All procedures were completed. They comprised four cases of laparoscopic assisted surgery, four of DaVinci robotic surgery, and two of open surgery. The mean operation time was 212.7±33.2 mins, mean anastomosis time (51.6±5.3) minutes, mean tunnel preparation time (20.0±3.5) minutes, and mean operative blood loss (90.0±51.6) mL. The time to first postoperative passage of flatus was (64.8±11.5) hours. The mean hospital stay after surgery was (9.2±1.7) days. There were no postoperative complications above Clavien-Dindo Grade II. The mean preoperative Reflux Disease Questionnaire score was (3.3± 0.4) before the surgery, (3.8±1.0) 1 month postoperatively, and (3.3±0.4) 12 months postoperatively. All patients underwent endoscopic follow-up; no anastomotic stenoses were found. However, one patient had Grade A reflux esophagitis 1 year after surgery and another Grade B reflux esophagitis 2 years after surgery. Conclusion: Esophagogastrostomy by the tunnel technique is a safe and feasible means of performing proximal gastrectomy.

447. SAFETY AND FEASIBILITY OF DOUBLE FLAP RECONSTRUCTION (KAMIKAWA TECHNIQUE) AS ANTI-REFLUX MECHANISM AFTER GASTROESOPHAGEAL SURGERY

Abstract Background Gastroesophageal reflux is a common adverse effect after oncological surgery for tumors of the gastroesophageal junction. Some of the reasons are the radicality of the intervention as well as the placement of the anastomosis inside the thoracic cavity, where there is a constant negative pressure. In recent years, multiple methods of digestive tract reconstruction have been developed in order to re-establish this anti-reflux mechanism, such as the double flap reconstruction, first described by Kamikawa, consisting of the creation of a seromuscular flap covering the anastomosis. Methods We designed a retrospective observational and descriptive study including all patients who underwent esophagogastric surgery and Kamikawa doble-flap reconstruction technique from January 2019 to January 2024. The operation conditions, postoperative recovery, postoperative complications (both short and mid-long term), and follow-up data were collected and analyzed. Quantitative variables are described as median and range, and qualitative variables as absolute number and percentage. The IBM SPSS Statistics 22 software was used for the descriptive part. Results We included a total of 10 patients in our series. All of them underwent an esophagogastric resection followed by a doble-flap reconstruction technique. Thoracoscopy in prone position was the approach used in most of the patients. In these cases, the doble flap was performed using the posterior wall of the gastric remnant. Half of the patients had no postoperative complications and the other half, mild ones. Postoperative manometry and pHmetry were only performed in 4 patients due to technical difficulties. In all these cases the tests showed no alterations. Despite this, one patient reported reflux, which was controlled with PPIs. Conclusions The double flap reconstructive technique is a useful tool that can be applied to those patients undergoing an aggressive procedure in the gastroesophageal junction in order to restore its valvular mechanism. It can be performed through different approaches that best fit each surgical scenario. It does not bear greater postoperative complications than standard procedures and may prove to be a good option to improve the quality of life of selected patients.

376. DOUBLE FLAP RECONSTRUCTION (KAMIKAWA TECHNIQUE) AS ANTI-REFLUX MECHANISM AFTER GASTROESOPHAGEAL SURGERY

Abstract Background Gastroesophageal reflux is a frequent adverse effect after oncological surgery of the gastroesophageal junction because of the radicality of the intervention and the placement of the anastomosis inside the thoracic cavity. Different surgical techniques have been developed that seek to re-establish this anti-reflux mechanism, such as the double flap reconstruction, first described by Kamikawa, which consists of the creation of a seromuscular flap surrounding the anastomosis. Methods Retrospective observational and descriptive study including all patients in whom this technique has been performed from January 2019 to January 2023. Quantitative variables are described as median and range, and qualitative variables as absolute number and percentage. The IBM SPSS Statistics 22 software was used for the descriptive part. Results A total of 8 patients were operated. In 2 cases the anastomosis was performed by laparotomy, 1 by laparoscopy, 4 by right thoracoscopy and 1 by left thoracoscopy. Half of the patients had no postoperative complications and the other half had mild ones. Manometry and pHmetry were requested of all patients after 6 months but only performed in 2 due to technical difficulties. In both cases the tests showed no alterations, but one of the patients reported reflux controlled with PPIs. Other suffered from occasional dysphagia and was being treated with periodic endoscopic dilatations. Conclusions The double flap reconstructive technique is a useful tool that can be applied to those patients undergoing an aggressive procedure in the gastroesophageal junction in order to restore its valvular mechanism. It can be performed through different approaches that best fit each surgical scenario. It does not bear greater postoperative complications than standard procedures and may prove to be a good option to improve the quality of life of selected patients.

Bowel seromuscular flaps used to repair pelvic defects in patients undergoing reoperative surgery.

Pedicled seromuscular bowel flaps may serve as an alternative for pelvic floor reconstruction when conventional omental and muscular flaps are not an option in patients undergoing reoperative abdominopelvic surgery. The aim of this study was to evaluate a unique series of bowel seromuscular flaps used to obliterate intrapelvic defects. We conducted a retrospective study on all patients in a single tertiary care institutional database who had undergone pelvic reconstruction with a seromuscular bowel flap from January 2006 to December 2018. The primary outcomes measured were the 30-day morbidity and mortality rates. Twelve patients (6 men 6 women, median age 56.5years [range 33-77years]) underwent reoperative abdominopelvic surgery requiring the use of a native small or large seromuscular bowelflap to obliterate pelvic defects. The indications for surgery included chronic infections, fistulizing Crohn's disease, and cancer. In all cases, no residual omentum was available and rectus abdominis muscle flaps were not feasible due to prior operative scars. Thirty-day morbidity occurred in 5 patients (42%), and included urine leak from ureteral injury, anastomotic leak, acute kidney injury, and superficial surgical site infection. No flaps became ischemic or required removal in the postoperative setting. No mortality was recorded. Bowel seromuscular flaps are a feasible and safe alternative for covering pelvic defects in patients who are undergoing reoperative surgery without the option to use traditional omental and muscular flaps.

History and present situation of seromuscular flap anastomosis in proximal gastrectomy

With the increasing detection rate of early upper gastric cancer and adenocarcinoma of esophagogastric junction, the safety of proximal gastrectomy with clear indications has been verified, and function-preserving proximal gastrectomy has been widely used. However, proximal gastrectomy destructs the normal anatomical structure of esophagogastric junction, resulting in severe postoperative gastroesophageal reflux symptoms and seriously affecting the quality of life. Among various anti-reflux surgery methods, reconstruction of "cardiac valve" has always been the focus of relevant scholars because its similarity with the mechanism of normal anti-reflux. After years of development, evolution and optimization, the designed seromuscular flap anastomosis includes tunnel muscle flap anastomosis, Hatafuku valvuloplasty, single muscle flap anastomosis and double muscle flap anastomosis. The double muscle flap anastomosis has become a research hotspot because it shows good anti-reflux effect in clinical application. This paper reviews the history, research status and hot issues of seromuscular flap anastomosis of esophageal remnant stomach at home and abroad.

Prolonged ischemia of the ileum and colon after surgical mucosectomy explains contraction and failure of “mucus free” bladder augmentation

Mucus production by the intestinal segment used in bladder augmentation results in long term concerns especially stones and UTI. Bladder augmentation with demucosalized intestinal flap is a potential promising approach for mucus-free bladder augmentation, however the contraction of the flap remains a major concern. Mucosectomy has been shown to result in abrupt and immediate cessation of microcirculation in the ileum. However, assessment of microcirculation shortly after mucosectomy may miss a gradual recovery of micro-circulation over a longer period of time. Previous studies have not assessed the colon response to mucosectomy. Our aim was to assess the effect of mucosectomy on the microcirculation of the colon and ileum beyond the known warm ischemia time. Ileum and colon segments were detubularised and mucosectomy was performed in (n=8) anesthetised minipigs. Group A: sero-musculo-submucosal flaps were created with removal of the mucosa and preserving the submucosal layer Group B: sero-muscular flaps were created with the removal of submucosal-mucosal layer. The Microvascular Flow Index (MFI), the velocity of the circulating red blood cells (RBCV) was measured using Intravital Dark Field (IDF) side stream videomicroscopy (Cytoscan Braedius, The Netherlands) after mucosectomy, for up to 180min. Both the MFI and RBCV showed an abrupt reduction of microcirculation, on both surfaces of the remaining intestinal flap, in the ileum as well as in the colon. Slightly better values were seen in Group A of the colon, but even these values remain far below the preoperative (control) results. Some, tendency of recovery of the microcirculation was noted after 60-90min, but this remained significantly lower than the preoperative control values at 180min. Both the ileal and the colonic flap remains in severe ischemia after mucosectomy beyond the warm ischemia time. This study shows that surgical mucosectomy compromises vascular integrity of the intestinal flaps used for bladder augmentation. Partial recovery which occurs within the warm ischemia time is not significant enough to avoid fibrosis therefore flap shrinkage may be inevitable with this technique. The gastrointestinal structure of the porcine model is not the same exactly as the human gastrointestinal system. However, although not an exact match it is the closest, readily available animal model to the human gastrointestinal system.

362 SUPERIOR POLAR GASTRECTOMY ASSOCIATED WITH ANTI-REFLUX TECHNIQUE: CASE REPORT

Abstract Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence. Methods This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer. Results A 55 year-old female diagnosed with gastric adenocarcinoma. Tumor was 3 cm long, from esophago-gastric junction to subcardial region (cT3N1M0). Patient underwent perioperative chemotherapy and surgical intervention 6 weeks later. A laparoscopic superior polar gastrectomy was performed and D1+ lymphadenectomy. A laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of gastric pouch and two seromuscular flaps were dissected. Gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis. Seromuscular flaps were sewn overlapping the esophago-gastric anastomosis. Patient presented an optimal postoperative evolution, without heartburn, dysphagia neither vomiting. Conclusion The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.

Safety and feasibility of laparoscopic double-flap technique in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction tumors larger than 5 cm

Objective: To investigate the safety and feasibility of laparoscopic double-flap technique (Kamikawa) in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction (EGJ) leiomyoma and gastrointestinal stromal tumor (GIST) with the maximum diameter >5 cm. Methods: A descriptive case-series study was used to retrospectively analyze the data of patients with EGJ leiomyoma and GIST undergoing laparoscopic-assisted proximal gastrectomy and double-flap technique (Kamikawa) at the Department of Gastrointestinal Surgery, Guangdong Hospital of Traditional Chinese Medicine from September 2017 to March 2019. All the tumors invaded the cardia dentate line, and the maximum diameter was >5 cm. After the exclusion of patients requiring emergency surgery and complicating with severe cardiopulmonary diseases, a total of 4 patients, including 3 males and 1 female with age of 29-49 years, were included in this study. After laparoscopic-assisted proximal gastrectomy, the residual stomach was pulled out of the abdominal cavity and marked with methylene blue at the proximal end 3~4 cm from the anterior wall of the residual stomach in the shape of "H". The gastric wall plasma muscular layer was cut along the "H" shape, and the space between the submucosa and the muscular layer was separated to both sides along the longitudinal incision line to make the seromuscular flap. The residual stomach was put back into the abdominal cavity. Under laparoscopy, 4 stitches were intermittently sutured at the upside of "H" shape and 4-5 cm from the posterior wall of the esophageal stump. The stump of the esophagus was cut open, and the submucosa and mucosa were cut under the "H" shape to enter the gastric cavity. The posterior wall of the esophageal stump was sutured continuously with the gastric stump mucosa and submucosa under laparoscopy. The anterior wall of the esophageal stump was sutured continuously with the whole layer of the residual stomach. The anterior wall of the stomach was sutured to cover the esophagus. The anterior gastric muscle flap was sutured and embedded in the esophagus to complete the reconstruction of digestive tract. The morbidity of intraoperative complications and postoperative reflux esophagitis and anastomosis-related complications were observed. Results: All the 4 patients completed the operation successfully, and there was no conversion to laparotomy. The median operative time was 239 (192-261) minutes, the median Kamikawa anastomosis time was 149 (102-163) minutes, and the median intraoperative blood loss was 35 (20-200) ml. The abdominal drainage tube and gastric tube were removed, and the fluid diet was resumed on the first day after surgery in all the 4 patients. The median postoperative hospitalization time was 6 (6-8) days. Postoperative pathology revealed 3 leiomyomas and 1 GIST. There were no postoperative complications such as anastomotic leakage or stenosis, and no reflux symptoms were observed. The median follow-up time was 22 (11-29) months after the operation, and no reflux esophagitis occurred in any of the 4 patients by gastroscopy. Conclusion: For >5 cm EGJ leiomyoma or GIST, double-flap technique (Kamikawa) used for digestive tract reconstruction after proximal gastrectomy is safe and feasible.

Single-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic Instruments.

Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed "double-flap" esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel laparoscopic instruments. Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra-abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110minutes each, and anastomosis took 75 and 46minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.

Transplantation of Autologous Peritoneum Using Ileal Seromuscular Flaps for Orthotopic Neobladder Reconstruction

Objective To develop an ideal surgical procedure for neobladder reconstruction in experimental porcine models. Methods Six experimental female pigs weighting 28-33 kg underwent transplantation of autologous peritoneum for bladder reconstruction under general anesthesia.The flaps were used to reconstruct the orthotopic neobladder by suturing with the edges of the triangle and neck of the remnant bladder.The ureteral catheters were removed on the 5 th postoperative day and the balloon catheter was removed on the 7 th postoperative day.Voiding behaviour was monitored.The animals were euthanized at week 12 for routine pathology,immunohistochemistry,and electron microscopy. Results All the pigs survived after the surgery,and no postoperative complication such as peritonitis,intestinal obstruction,or urinary fistula was observed.All the peritoneum-ileum composite free valves survived after transplantation.Voiding behaviour was normal after catheter removal,and the urine was clear.At autopsy,reconstructed bladders were healthy.Pathological examination showed the neobladder had been covered by continuous urothelium while the peritoneum disappeared and showed no ileal mucosa regrowth and residual.Scanning electron microscope showed the transitional cells of neobladder were complete and orderly,and the urothelium around suture border was continuous and showed no malposition. Conclusions Reconstruction of bladder by autologous peritoneum and ileal seromuscular flaps is an ideal approach in the experimental pigs as it can prevent regrowth of ileal epithelial cells and avoid the complications of conventional enterocystoplasty.Its clinical application deserves further investigations.

Reconstruction of Complex Abdominal Wall Defect With Autogenous Pedicled Demucosalized Seromuscular Flap

Abdominal wall reconstruction is indicated when 1 or more of the abdominal wall components (skin, fascia, or muscle) are either injured or absent. When faced with defects requiring flap reconstruction, the decision regarding flap choice should take into consideration the volume of soft tissue required, the extent of the defect, donor site morbidity, and prior surgical scars that affect flap vascularity. We present a case of an abdominal wall defect with limited reconstructive options in which a spare ileal bowel segment was filleted to create a seromuscular flap for improving the abdominal wall blood supply. The postoperative course was complicated by abdominal fluid collection, which resolved following an ultrasound-guided drain. The patient had normal wound healing and recovery without further postoperative complications at the 7-month follow-up. Seromuscular flaps are a practical option in the armamentarium of plastic surgeons performing abdominal wall reconstruction, especially when other alternatives are limited.

P198 SUPERIOR POLAR GASTRECTOMY ASSOCIATED WITH ANTI-REFLUX TECHNIQUE: CASE REPORT

Abstract Aim To present a case report where Kamikawa’s technique1 was used, as well as the patient’s postoperative evolution and results. Background and Methods Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence. This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer. Results A 55 year-old female with no relevant medical history, diagnosed with diffuse signet ring cell gastric adenocarcinoma. The tumor was 3 cm long, extending from the esophago-gastric junction to the subcardial region (cT3 N1 M0). After presentation in a Multidisciplinary Group, the patient underwent perioperative chemotherapy according to the FLOT-4 protocol, presenting partial clinical response. The surgical intervention took place 6 weeks after finishing chemotherapy, and a laparoscopic superior polar gastrectomy was performed, associating extended resection including 3-4 cm of distal esophagus and D1+ lymphadenectomy with periesophageal lymph node regions 110 and 111. Once the resection was finalized, an assistance laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of the cranial part of the gastric pouch and afterwards, two seromuscular flaps were dissected. Then, the gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis made with 2 running sutures of V-lock 3/0. Finally, the previously prepared seromuscular flaps were sewn overlapping the esophagus and the esophago-gastric anastomosis in order to prevent reflux. The patient presented a benign postoperative course, reintroducing oral intake and developing no heartburn, no dysphagia, nor vomiting and was discharged on the 9th postoperative day. The postoperative barium swallow radiography showed no leak of contrast nor any regurgitation. The pathology report showed pT3N1 (2/17) and confirmed tumor free resection margins. Conclusion The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.

An animal model of bladder reconstruction by autologous peritoneum transplantation

Objective: To establish experimental porcine model of reconstruction the neobladder by ileal seromuscular with transplantation of autologous peritoneum. Methods: This was an animal experiment carried out from January to April 2018 at animal center of Guizhou Medical University. Randomly 6 experimental female porcines were chosen, and their body weight was 28 to 33 kg. By intravenous anesthesia, the transplantation of autologous peritoneum for bladder reconstruction operation was carried out by transplanting the peritoneum onto an ileum segment which mucosa and submucosa had been removed. These flaps were used to mend and reconstruct the neobladder by suturing with edge of the detective bladder. After removal of ureteral catheters and balloon catheter at day 5 and day 7 respectively, voiding behavior was monitored, and animals were euthanized at week 12 for routine pathology, immunohistochemistry, and electron microscopic examinations. Results: Six porcines underwent reconstruction, but no one lost to complications such as peritonitis, ileus and urinary fistula. Voiding behavior was normal, and urine was clear in all animals after removal of catheters. At autopsy, reconstructed bladders were healthy. Pathological examination showed the part of reconstruction had been covered by continuous urothelium while the peritoneum disappeared and showed no ileal mucosa regrowth and residual. Scanning electron microscope showed that the transitional cells of neobladder were complete and orderly, and urothelium around suture border was continuous and no malposition. Conclusion: In this experimental porcine model, reconstruction bladder by autologous peritoneum and ileal seromuscular flaps is an ideal approach.

Mucosectomy disrupting the enteric nervous system causes contraction and shrinkage of gastrointestinal flaps: potential implications for augmentation cystoplasty

Augmenting the bladder with a seromuscular gastrointestinal flap is a promising alternative approach aiming for a mucus-free bladder augmentation; however, the contraction (shrinkage) of the flaps remains a major concern. Enteric nervous system (ENS) abnormalities cause a failure of relaxation of the intestinal muscle layers in motility disorders such as Hirschsprung's disease and intestinal neuronal dysplasia. In mammals, the submucosal enteric nervous plexus contains nitrergic inhibitory motor neurons responsible for muscle relaxation. The authors hypothesize that mucosectomy disconnects the submucosal nervous plexus from the myenteric plexus resulting in flap shrinkage. After ethical approval, mucosectomy was performed on vascularized flaps from the ileum, colon, and stomach in five anesthetized pigs. In Group (I), only the mucosa was scraped off with forceps, creating a sero-musculo-submucosal flap, while in Group (II), the mucosa and submucosa were peeled off as one layer, leaving a seromuscular flap. Isolated and detubularized segments served as control. The width of each flap was measured before and after the mucosectomy. The ENS was assessed by neurofilament immunohistochemistry in conventional sections and by acetylcholinesterase and NADPH-diaphorase enzyme histochemistry in whole-mount preparations. The stomach contracted to a lesser extent of its original width, 92.82±7.86% in Group (I) and 82.24±6.96% in Group (II). The ileum contracted to 81.68±4.25% in Group (I) and to 72.675±5.36% in Group (II). The shrinkage was most noticeable in the colon: 83.89±15.73% in Group (I) and to 57.13±11.51% in Group (II). One-way equal variance test showed significant difference (P<0,05) between Group (I) and (II), comparing stomach with ileum and ileum with colon. The histochemistry revealed that the submucosal nervous plexus containing nitrergic inhibitory neurons was disconnected from the myenteric plexus in Group (II) of all specimens. Mucosectomy resulted in significant immediate shrinkage of the flaps. This was more expressed when also the submucosa was peeled off, thus fully disrupting the ENS. The shrinkage affected the stomach the least and the colon the greatest. This phenomenon should be taken into consideration when planning mucus-free bladder augmentation.

742 – Small Bowel Seromuscular Flaps Used for Pelvic Defects in Patients Undergoing Reoperative Surgery

742 – Small Bowel Seromuscular Flaps Used for Pelvic Defects in Patients Undergoing Reoperative Surgery

Kamikawa Double-Flap Reconstruction After Minimally Invasive Ivor-Lewis Esophagectomy

Despite the high incidence of reflux esophagitis, there are few reports of antireflux modifications for minimally invasive Ivor-Lewis esophagectomy. We present the case of a 63-year-old man with mid-thoracic esophageal squamous cell carcinoma who underwent minimally invasive Ivor-Lewis esophagectomy after neoadjuvant chemoradiotherapy. Laparoscopic dissection, gastric tube creation, and mobilization was performed. Thoracoscopic esophageal dissection, subcarinal, paraesophageal and diaphragmatic lymphadenectomy were performed, followed by esophagogastric anastomosis with double seromuscular flap reconstruction to recreate the lower esophageal sphincter. The operation was completed in 618 minutes with 200 mL blood loss and the patient recovered uneventfully. A morphologic sphincter was seen on postoperative contrast study.

Evaluation of autologous composite colo-peritoneal grafts in the repair of experimental urinary bladder defects in dogs

Background: Urinary bladder (UB) defects are most often associated with embryologic development and pelvic trauma. The cause of the defects could be congenital abnormalities or various aetiologies connected with modern life, including road traffic accidents, assault (gunshot injuries) and occupational hazards (neoplasia). industrial, and criminal activities. Medical treatment for these defects is mostly limited thereby necessitating surgical intervention. This study was aimed at finding alternative reconstruction tissue for restoring bladder storage and voiding capability. Materials and Methods: The surgical procedure was aseptically performed under general anesthesia. The dorsal aspect of the urinary bladder served as the recipient site, while sero-muscular colonic pedicle flap of the descending colon along with free peritoneal sheath formed a composite tissue (donor), colo-peritoneal pedicle graft. The surgical procedure included preparation of the colonic pedicle flap, preparation of free peritoneal flap, formation of composite colo-peritoneal graft, preparation of urinary bladder graft bed, and colo-peritoneo-cystoplasty. The dogs were evaluated in the post-operative period by physical examination, urinalysis, and cystography within the duration of 14 weeks. Results: Cystographic evaluations performed on the 2nd, 10th, and 14th weeks post surgery revealed gradual transition of the urinary bladder architecture at the point of graft with clear delineation and minimal blurring at initial assessment, which gradually disappeared later. Complications observed were straining and constipation, which responded positively following appropriate interventions. Post surgical urinalysis showed transient changes in specific gravity and urine pH values, but returned to pre surgical level after day 18 post surgery. Post surgical proteinuria was observed for the first 7 days, but disappeared on day 12. Hematuria occurred within the first 16 days post surgery. Conclusion: It was concluded that autologous composite colo-peritoneal tissue graft was successfully formed and effectively used in the repair of urinary bladder defects in the dogs. This surgical management intervention could be evaluated in human subjects with similar urinary bladder defects.

Pedicled gastric seromuscular patch for one-stage closure of a bronchopleural fistula: a case report

BackgroundOne-stage closure and fenestration are the available surgical options for bronchopleural fistula (BPF). One-stage closure may be applicable in cases with favorable infection control. Closing the bronchopleural stump is difficult due to thick adhesion caused by inflammation and a high risk of pulmonary artery injury. We report the successful closure of a BPF using a gastric seromuscular patch with an omental pedicle flap.Case presentationA 73-year-old man underwent right lower lobectomy with ND2a-2 lymph node dissection for lung adenocarcinoma. He was admitted to a local hospital for pneumonia. Three days after admission, his thoracic cavity was drained and a BPF was suspected. During the primary operation, the latissimus dorsi muscle and anterior serratus muscle were dissected via posterolateral incision, and we decided to close the fistula using the gastric seromuscular layer and omental pedicle flap. The patient was discharged 20 days after surgery. After 2 years, he has not had cancer recurrence and currently leads an active life.ConclusionsThis method provided immediate airtight closure and luminal opening of the middle bronchus in our patient with a large BPF and appeared superior to using the omentum alone. This procedure is useful for one-stage closure and does not require fenestration in cases with favorable infection control.

Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique

We developed a novel double-flap technique as an anti-reflux procedure following sin-gle-port laparoscopic proximal gastrectomy. After performing laparoscopic proximal gas-trectomy, an H-shaped seromuscular flap is created on the anterior wall of the gastric remnant and then reconstruction procedure is started. First, the posterior esophageal wall is fixed to the stomach at the cranial edge of the submucosal window. Second, the posterior wall of the esophagus and the gastric mucosa are sutured and layer-to-layer suturing is then performed between the anterior esophagus and stomach to complete the esophagogas-trostomy. Finally, the anastomotic site and distal esophagus are covered with the sero-muscular flap. All steps were performed using continuous barbed sutures to facilitate anastomotic procedures. The above mentioned procedure is safe and feasible for the treatment of gastric cancer with acceptable short- and mid-term results. Thus, this pro-cedure may be an attractive surgical option as a minimally invasive surgery.

Pure single-port laparoscopic proximal gastrectomy using a novel double-flap technique

We developed a novel double-flap technique as an anti-reflux procedure following sin-gle-port laparoscopic proximal gastrectomy. After performing laparoscopic proximal gas-trectomy, an H-shaped seromuscular flap is created on the anterior wall of the gastric remnant and then reconstruction procedure is started. First, the posterior esophageal wall is fixed to the stomach at the cranial edge of the submucosal window. Second, the posterior wall of the esophagus and the gastric mucosa are sutured and layer-to-layer suturing is then performed between the anterior esophagus and stomach to complete the esophagogas-trostomy. Finally, the anastomotic site and distal esophagus are covered with the sero-muscular flap. All steps were performed using continuous barbed sutures to facilitate anastomotic procedures. The above mentioned procedure is safe and feasible for the treatment of gastric cancer with acceptable short- and mid-term results. Thus, this pro-cedure may be an attractive surgical option as a minimally invasive surgery.