Quantitative Assessment of Blood Flow in the Gastric Conduit With Thermal Imaging for Esophageal Reconstruction.

OBJECTIVE: The study's primary aim was to evaluate the effectiveness of thermal imaging (TI) and its secondary aim was to compare TI and indocyanine green (ICG) fluorescence angiography, with respect to the evaluation of the viability of the gastric conduit. SUMMARY BACKGROUND DATA: The optimal method for evaluating perfusion in the gastric conduit for esophageal reconstruction has not been established. METHODS: We reviewed the prospectively collected data of 263 patients who had undergone esophagectomy with gastric conduit reconstruction. TI was used in all patients. ICG fluorescence was concomitantly used in 24 patients to aid comparison with TI. A cut-off value of the anastomotic viability index (AVI) was calculated using the receiver operating characteristic curve in TI. RESULTS: Anastomotic leak was significantly less common in patients with AVI > 0.61 compared with those with AVI ≤ 0.61 (2% vs 28%, P< 0.001). Microvascular augmentation was performed in 20 patients with a low AVI score and/or preoperative chemoradiotherapy. Overall ability was comparable between TI and ICG fluorescence regarding the qualitative evaluation of the gastric conduit. However, TI was superior in the quantitative assessment of viability. CONCLUSIONS: TI could delineate the area of good perfusion in the gastric conduit for esophageal reconstruction, which can help identify patients at high risk of anastomotic leak.

Early prediction of complex benign anastomotic stricture after esophagectomy using early postoperative endoscopic findings.

BACKGROUND: Benign anastomotic stricture after esophagectomy and reconstruction adversely affects oral intake and can increase the risk of aspiration pneumonia. Some patients experience relapse that requires frequent endoscopic dilatations. This study aimed to investigate whether the endoscopic appearance of anastomosis during the early postoperative period is associated with the complexity of subsequent anastomotic strictures. METHODS: Data of 213 patients who underwent esophagectomy with gastric tube reconstruction and early postoperative endoscopy between July 2008 and September 2018 were prospectively collected. Relationships among various risk factors, including the severity of mucosal degeneration of the anastomosis and complexity of anastomotic stricture, were studied using multivariate logistic regression analysis. RESULTS: Fifty-three patients (25%) developed anastomotic strictures at a median of 55 days after surgery, requiring a median of 5 endoscopic dilations. In multivariate analysis, severe mucosal degeneration was the only significant risk factor for any type of anastomotic stricture (P < 0.001). Twenty-seven patients (51%) developed refractory anastomotic strictures. In multivariate analysis, younger age (< 65 years) (P = 0.01), lack of neoadjuvant therapy (P = 0.02), severe mucosal degeneration (P = 0.03), and stricture development within 55 days (P = 0.01) were the risk factors for refractory stricture. The analysis of the risk factors for severe mucosal degeneration revealed that comorbidities and anastomotic techniques were independently correlated (P < 0.01). CONCLUSIONS: Early postoperative severe mucosal degeneration of esophagogastrostomy was the only predictor of strictures, regardless of their type. Mucosal degeneration, early postoperative stricture, younger age, and front surgery were associated with refractory anastomotic strictures.

Association of level of anastomosis and anastomotic leak after esophagectomy in anterior mediastinal reconstruction.

AIM: The purpose of this study was to investigate modifiable predisposing factors associated with anastomotic leak in the anterior mediastinal (AM) reconstruction route. METHODS: We reviewed the data on 154 patients who underwent esophagectomy and gastric tube reconstruction using the AM route between 2008 and 2016. The data included computed tomography (CT) scans with sagittal reconstruction of the thoracic section. The level of the esophagogastric anastomosis (LEA) and pretracheal distance (PTD) was measured from sagittal reconstructed CT images. Vascularization of the gastric tube was evaluated by postoperative endoscopy. Variables associated with anastomotic leak were determined using univariate and multivariate analyses. RESULTS: Anastomotic leak developed in 13 patients (8%). The cut-off level at which the anastomosis was less likely to develop a leak, as determined by Chi-square tests, was 1.5 cm for LEA and 1.3 cm for PTD. On univariate analysis, the factors that were significantly associated with the risk of anastomotic leak included diabetes, hand-sewn anastomosis, the LEA ≥ 1.5 cm, and severe mucosal degeneration. On multivariate analysis, diabetes (OR 4.7, 95% CI 1.29-17.2), LEA ≥ 1.5 cm (OR 20.1, 95% CI 3.15-128), and severe mucosal degeneration (OR 7.2, 95% CI 1.42-36.8) were found to be statistically significant independent risk factors. CONCLUSION: Use of the AM route to place the cervical anastomosis within 1.5 cm above the suprasternal notch might avoid excessive pressure on the gastric tube from the surrounding structures, resulting in a reduction in the risk of an anastomotic leak.

Laparoscopic sentinel node navigation surgery for early gastric cancer: a prospective multicenter trial.

BACKGROUND: Prospective multicenter trials have shown the feasibility of sentinel node (SN) navigation surgery using a dual tracer of dye and radioisotope for early gastric cancer. However, comparable trials using the indocyanine green (ICG) and the infrared ray laparoscopic system (IRLS) have not been reported. On the basis of our cohort studies, we assumed that the ICG imaging with the IRLS is as effective as the dual tracer in detecting SNs. Therefore, we conducted a prospective multicenter trial to assess the effectiveness and generalizability of the infrared ICG technique in patients with early gastric cancer. PATIENTS AND METHODS: Patients with previously untreated cT1 gastric adenocarcinomas less than 4 cm in gross diameter were eligible for inclusion in this study. SN mapping was performed by using ICG combined with IRLS technique. Following biopsy of the identified SNs, D2 or modified D2 laparoscopic gastrectomy was performed according to the current Japanese Gastric Cancer Association guidelines. RESULTS: Among the 47 patients who gave written informed consent, 44 were eligible from the surgical findings, for whom SN biopsy was performed. The detection rate of the lymphatic basin by the ICG with IRLS was 100% (44/44). The accuracy was also 100% (7/7) for detecting metastatic lymph node, which was verified on the permanent pathologic examination. Following the median follow-up of 114 months (range, 60 to 120 months), no recurrence (0/40) was observed. Although the number of patients was unequally distributed among the hospitals participating in the trial, the detection rates of SNs in low-volume hospitals were comparable to those in high-volume hospitals. Consequently, there was no learning curve in this trial. CONCLUSION: The infrared ICG imaging accurately detected the lymphatic basin and SNs with occult metastasis in SN-navigated gastrectomy for gastric cancer. This method was feasible even for low-volume surgeons and hospitals.

Early postoperative endoscopy for targeted management of patients at risks of anastomotic complications after esophagectomy.

BACKGROUND: Early postoperative endoscopy after esophagectomy is assumed to be effective in detection and prediction of anastomotic complications, but overall effects of early postoperative endoscopy remain uncertain. The aim of this study was to investigate whether mucosal status assessed by early postoperative endoscopy could offer an approach to individualized management after esophagectomy. METHODS: Endoscopy was performed in 176 of 214 patients who underwent esophagectomy at either 1 week or 2 weeks postoperatively. Mucosal damage in the proximal region of the graft was classified as follows: intact mucosa, mild mucosal degeneration, and severe mucosal degeneration. We examined the association of the severity of mucosal damage and the incidence of anastomotic complications. RESULTS: Twenty-eight patients (16%) developed anastomotic stricture. Symptomatic anastomotic leaks occurred in 15 patients (8.5%), including 6 with stricture. The frequency of intact mucosa, mild mucosal degeneration, and severe mucosal was 7%, 20%, and 73% for leaks; 4%, 11%, and 85% for strictures; and 28%, 62%, and 10% for no complications, respectively (P <.001). Asymptomatic leaks were found in 4 patients in the 1-week endoscopy group. Sensitivity and specificity for the development of stricture in 1-week/2-week were 0.88/0.83 and 0.85/0.98, respectively. Positive and negative predictive values were 0.52/0.91 and 0.97/0.96, respectively. Early postoperative endoscopy could be carried out without any adverse events in all patients. CONCLUSION: Assessment of the anastomosis and graft with early postoperative endoscopy was safe and resulted in a high predictive value for subsequent anastomotic complications. Early postoperative endoscopy may lead to targeted management for a subset of patients undergoing esophagectomy.