Surgical management of right hepatectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report and literature review.

BACKGROUND: Coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) is a well-established, safe procedure. However, problems with RGEA grafts in subsequent abdominal surgeries can lead to fatal complications. This report presents the first case of right hepatectomy for hepatocellular carcinoma after CABG using the RGEA. CASE PRESENTATION: We describe a case in which a right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft. Preoperatively, three-dimensional computed tomography (3D- CT) images were constructed to confirm the run of the RGEA graft. The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft. The RGEA graft had formed adhesions with the hepatic falciform ligament, necessitating meticulous dissection. After the right hepatectomy, the left hepatic lobe descended into the vacated space, exerting traction on the RGEA. However, this traction was mitigated by suturing the hepatic falciform ligament to the abdominal wall, ensuring stability of the RGEA. There were no intraoperative or postoperative complications. CONCLUSION: It is crucial to confirm the functionality and anatomy of the RGEA graft preoperatively, handle it gently intraoperatively, and collaborate with cardiovascular surgeons.

Distribution of Perigastric Station 4d Lymph Nodes in Vascularized Gastroepiploic Lymph Node Transfer: An Anatomic Study and Case Series.

BACKGROUND: Vascularized gastroepiploic lymph node transfer (VGLNT) is a well-accepted surgical treatment for restoring physiological function in chronic lymphedema. However, the inclusion of substantial lymph nodes (LNs) in the flap remains uncertain. This study aimed to identify the anatomical basis for reliable flap harvest for VGLNT. PATIENTS AND METHODS: The anatomy of perigastric station 4d LNs was studied in healthy cadavers (n = 15) and patients with early gastric cancer (EGC) (n = 27). The omentum was divided into three segments: proximal, middle, and distal from the origin of the right gastroepiploic vessels. The flap dimension, number, location, size of LNs, and caliber of the vessels were reviewed. Eight patients underwent VGLNT for upper/lower limb lymphedema. RESULTS: The mean numbers of LNs in the proximal, middle, and distal segment were 2.5, 1.4, 0.5 in the cadavers, and 4.9, 2.7, 0.7 in the gastrectomy specimens, respectively. The proximal third included a significantly greater number of LNs than the distal third in the cadaveric (p = 0.024) and ECG (p = 0.016) specimens. A total of 95% of the LNs were located within proximal two-thirds of the flap from the vessel origin both in the cadavers (21.0 × 5.0 cm) and in the gastrectomy specimens (20 × 3.5 cm). In VGLNT, the transferred flap was 25.5 ± 6.9 × 4.1 + 0.7 cm in dimension, containing a mean number of 6.5 ± 1.9 LNs. At postoperative 6 months, the volumetric difference was significantly reduced by 22.8 ± 9.2% (p < 0.001). CONCLUSIONS: This study provides a distinct distribution pattern of station 4d LNs. Inclusion of the proximal two-thirds of the flap, which carries majority of the LNs, is recommended for VGLNT.

Right gastroepiploic artery length determined anastomotic leakage after minimally invasive esophagectomy for esophageal cancer: a prospective cohort study.

BACKGROUND: This prospective cohort study, conducted at a high-volume esophageal cancer center from July 2019 to July 2022, aimed to investigate the link between the right gastroepiploic artery (RGEA) length and anastomotic leakage (AL) rates following minimally invasive esophagectomy (MIE). Real-world data on stomach blood supply in the Chinese population were examined. MATERIALS AND METHODS: A total of 516 cases were enrolled, categorized into two groups based on the Youden index-determined optimal cut-off value for the relative length of RGEA (length of RGEA/length of gastric conduit, 64.69%) through ROC analysis: Group SR (short RGEA) and Group LR (long RGEA). The primary observation parameter was the relationship between AL incidence and the ratio of direct blood supply from RGEA. Secondary parameters included the mean length of the right gastroepiploic artery, greater curvature, and the connection type between right and left gastroepiploic vessels. Patient data were prospectively recorded in electronic case report forms. RESULTS: The study revealed median lengths of 43.60 cm for greater curvature, 43.16 cm for the gastric conduit, and 26.75 cm for RGEA. AL, the most common postoperative complication, showed a significant difference between groups (16.88 vs. 8.84%, P =0.01). Multivariable binary logistic regression identified Group SR and LR (odds ratio: 2.651, 95% CI: 1.124-6.250, P =0.03) and Neoadjuvant therapy (odds ratio: 2.479, 95% CI: 1.374-4.473, P =0.00) as independent predictors of AL. CONCLUSIONS: The study emphasizes the crucial role of RGEA length in determining AL incidence in MIE for esophageal cancer. Preserving RGEA and fostering capillary arches between RGEA and LGEA are recommended strategies to mitigate AL risk.

[Hemodynamics in the right gastroepiploic artery and its practical application]. / Formula gemodinamiki pravoi zheludochno-sal'nikovoi arterii i ee prakticheskoe primenenie.

OBJECTIVE: To study functional anatomy of the right gastroepiploic artery (RGEA), its gastric and omental branches and practical significance of these anatomical features. MATERIAL AND METHODS: We analyzed 20 cadaveric organ complexes (11 men and 9 women, aged 49-85 years) between 2018 and 2019. The organ complexes consisted of the stomach, proximal duodenum and large omentum. RGEA catheterization at the level of pylorus was followed by selective real time angiography. We assessed the following parameters of RGEA: total length, diameter at the level of pylorus, number and diameter of gastric and omental branches. To objectify the study, we visually divided RGEA into 5 equal segments between pylorus and the last branch arising from this artery. RESULTS: The RGEA looks like a gradually and evenly narrowing tube. Mean diameter of the artery at the level of pylorus was 2.2±0.68 mm, mean length - 23.6±3.7 cm. Mean number of gastric and omental branches was 16.2±4.8 and 8.6±2.6, respectively. The number of gastric branches in the distal part of the RGEA increased, while the diameters of the gastric branches did not significantly differ. The number of gastric branches in distal RGEA increased, while diameters of gastric branches were similar. The greatest number of omental branches with the largest diameter was observed in the 2nd and 3rd segments of the artery. Considering these data, we formulated the equation for RGEA hemodynamics and developed the technique for optimal blood supply to proximal part of the gastric transplant during esophagogastroplasty. CONCLUSION: Anatomical features of the right gastroepiploic artery can be used in reconstructive surgery of abdominal cavity and chest.

Preoperative Computed Tomography of the Right Gastroepiploic Artery for Coronary Artery Bypass Grafting.

BACKGROUND: Grafting the right gastroepiploic artery (GEA) to the right coronary artery (RCA) is effective, but preoperative evaluation of arterial conduit availability has not been established. By comparing the midterm graft results, we aimed to assess the efficacy of preoperative evaluation of the GEA using computed tomography (CT).Methods and Results: We retrospectively examined patients who underwent isolated coronary artery bypass grafting surgery between April 2010 and December 2020, and those whose GEA was grafted to the RCA were selected: 55 patients were included in the study analysis. Postoperative evaluations were performed during the early phase, 1 year postoperatively, and at follow-up evaluations. The outer diameter of the proximal GEA was compared with the midterm graft patency grade on CT and patients were classified as Functional (Grade A) or Dysfunctional (Grades O or B). The proximal GEA outer diameters were significantly different between the Functional and Dysfunctional groups (P<0.001). Furthermore, multivariate Cox regression analysis revealed that this diameter was an independent predictor of graft functionality (P<0.001). Patients with outer proximal diameters larger than the cutoff value had superior graft results at 3 years postoperatively. The rate of freedom from a dysfunctional graft at 3 years postoperatively was 95.5% and 45.5% for the Larger and Smaller diameter subgroups, respectively (P<0.001). CONCLUSIONS: Preoperative evaluation of the outer diameter of the proximal GEA, excluding calcified GEA, using CT is a minimally invasive and useful method, and may improve midterm results of in-situ GEA grafting, even in severe stenotic lesions.

A case of transcatheter arterial embolization for intraperitoneal hemorrhage due to giant hepatic segmental arterial mediolysis.

This study aimed to demonstrate the effect of transcatheter arterial embolization (TAE) on hepatic segmental arterial mediolysis (SAM). The patient, a 68-year-old female, suddenly developed right upper abdominal pain in October 2021, which was initially relieved. However, she was rushed to a local hospital the next day when her abdominal pain recurred. An abdominal computed tomography scan suggested a ruptured hepatic aneurysm; therefore, she was transferred to our hospital and admitted on the same day. On the first day after admission, she underwent emergency catheterization and N-butyl-2-cyanoacrylate (NBCA)/lipiodol embolization for an aneurysm in the hepatic S6. A multi-detector computed tomography on hospital day 8 to probe for extrahepatic lesions revealed multiple beaded irregularities in the superior mesenteric and bilateral renal arteries. A head magnetic resonance angiography performed on the ninth day showed no aneurysms or irregularities. She did well after TAE, did not have rebleeding, and was discharged on hospital day 16. Rupture of an aneurysm associated with SAM occurs frequently in the colonic and gastroepiploic arteries, and rupture of a hepatic aneurysm is relatively rare. TAE hemostasis was able to save the patient by preventing intraperitoneal bleeding caused by hepatic segmental arterial mediolysis.

Real-time vessel navigation using indocyanine green fluorescence during robotic-assisted gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery.

Injury to the right gastroepiploic artery (RGEA) graft during gastrectomy after coronary artery bypass grafting (CABG) can cause critical coronary failure. A man in his 60s with advanced gastric cancer and a history of CABG was admitted to our hospital. His cardiac blood flow was dependent on RGEA, and a gastrectomy with RGEA preservation was necessary. Robot-assisted distal gastrectomy with real-time vessel navigation using indocyanine green (ICG) fluorescence imaging and Da Vinci Firefly technology was planned. Intraperitoneal observation revealed severe adhesions around the graft. Two milliliters ICG (2.5 mg/mL) was injected intravenously, and RGEA was visualized. An RGEA-preserving robot-assisted distal gastrectomy was successfully performed. The operation time was 279 minutes, and the blood loss was 5 mL. The postoperative course was good and there were no complications.

I-Composite Graft with Right Internal Thoracic Artery and Right Gastroepiploic Artery in Coronary Artery Bypass Grafting.

PURPOSE: When added to the internal thoracic artery (ITA), the right gastroepiploic artery (GEA) has been used as an in-situ graft or an I-composite right ITA-right GEA graft in coronary artery bypass grafting (CABG). We aimed to verify its potential. METHODS: We evaluated 104 patients who underwent first isolated CABG with this I-composite graft. The number of distal anastomoses, graft flow (GF) and pulsatility index (PI) during surgery, and graft patency in the early term regarding this I-composite graft were evaluated. RESULTS: The number of total distal anastomoses and distal anastomoses with arterial grafts were 4.17 ± 0.81 and 3.63 ± 0.81, respectively. This I-composite graft achieved 2.38 ± 0.69 distal anastomoses. GF tended to increase according to the increased number of distal anastomoses (p = 0.241), and the PI maintained a low score regardless of the number of distal anastomoses (p = 0.834). Graft patency was 95.5%; moreover, the number of distal anastomoses with this I-composite graft did not affect early-term graft patency. CONCLUSION: Right GEA utility was expanded as this I-composite graft in addition to in-situ graft. This I-composite graft has an adequate flow capacity for revascularization in non-left anterior descending coronary artery lesions.

Diaphragmatic hernia post coronary artery bypass with gastroepiploic artery.

An 86-year-old man, with a medical history of coronary artery bypass grafting with the right gastroepiploic artery 20 years prior, was admitted to our hospital for right-sided heart failure. Computed tomography findings revealed an intrapericardial diaphragmatic hernia of the transverse colon compressing the right ventricle. The hernia was successfully repaired, and the patient recovered without any complications. Diaphragmatic hernia is rare but may be a lethal complication following coronary artery bypass grafting. We should be aware of the possibility of this condition.

Right gastroepiploic artery versus right internal thoracic artery composite grafts: 10-year patency and long-term outcomes.

OBJECTIVES: We compared the 10-year graft occlusion rates and long-term clinical outcomes of right gastroepiploic artery (RGEA) composite grafts with those of right internal thoracic artery (RITA) composite grafts. METHODS: From 2000 to 2008, 548 patients had undergone total arterial revascularization for multivessel coronary artery disease using the RGEA (RGEA group; n = 389) or RITA (RITA group; n = 159) as a second-limb Y-composite graft based on the in situ left ITA. A propensity score-matched analysis was used to match the RGEA group (n = 152) with the RITA group (n = 152). The 10-year angiographic occlusion rates and long-term clinical outcomes were compared. The follow-up data were complete for all 304 patients (100%) with a median follow-up of 143.7 months. RESULTS: The early clinical outcomes were similar between the matched groups. The overall graft occlusion rate was 9.5% at 10 years in the matched group patients (matched RGEA and RITA groups, 10.3% and 8.4%, respectively; P = .639). The 10-year occlusion rates of the second-limb conduits showed no differences between the matched RGEA and RITA groups (14.1% and 10.2%, respectively; P = .487). No statistically significant differences were found at 15 years postoperatively in the overall survival (52.9% vs 49.4%; P = .470), cardiac mortality-free survival (92.1% vs 90.9%; P = .560), freedom from target vessel revascularization (83.0% vs 91.4%; P = .230), freedom from reintervention (68.8% vs 76.2%; P = .731), or freedom from major adverse cardiac and cerebrovascular events (56.4% vs 64.6%; P = .364) rates between the matched groups. CONCLUSIONS: Total arterial revascularization using RGEA composite grafts showed comparable results to those using RITA composite grafts in terms of the 10-year occlusion rates and long-term clinical outcomes.

Does the Addition of a Gastroepiploic Artery to Bilateral Internal Thoracic Artery Improve Survival?

It is unclear whether the additional conduit to supplement bilateral internal thoracic arteries (BITA) influences the patient outcome in coronary surgery. This retrospective study compared long-term survival of patients undergoing left-sided BITA grafting in which the third conduit to the right coronary system (RCA) was either vein graft (SVG) or gastroepiploic artery (GEA). From 1989 to 2014, 1432 consecutive patients underwent left-sided revascularization with BITA associated with SVG (n = 599) or GEA (n = 833) to RCA. Propensity score was calculated by logistic regression model and patients were matched 1 to 1 leading to 2 groups of 320 matched patients. The primary end point was the overall mortality from any cause. GEA was used in significantly lower risk patients. The 30-day mortality was 1.6% without influence of the graft configuration. Postoperative follow-up was 13.6 ± 6.6 years and was 94% complete. The significant difference in patients' survival observed at 20 years in favor of GEA in unmatched groups (48 ± 4% vs 33 ± 6%, P < 0.001) was not confirmed in matched groups (41 ± 7% vs 36 ± 7%, P = 0.112). In multivariable Cox model analysis, the conduit used to RCA did not influence the long-term survival in matched groups, like no other graft configuration or operative parameter. Only complete revascularization remained predictor of survival (P = 0.016), with age (P < 0.0001), diabetes status (P = 0.007), and left ventricle ejection fraction (P < 0.0001). Long-term survival in patients undergoing BITA grafting is not affected by using GEA as third arterial conduit in alternative to SVG. Further studies are necessary to assess its impact on long-term cardiac events.

Saphenous Vein vs Arterial Graft to the Right System in Left-Sided Arterial Revascularization.

BACKGROUND: To investigate clinical outcomes of various arterial grafts (AGs) vs saphenous vein grafts (VGs) to the right coronary system in patients who received left-sided bilateral internal thoracic artery revascularization. METHODS: We compared short- and long-term outcomes of all the patients operated in our center during 1996-2011, who received left-sided bilateral internal thoracic artery (left anterior descending and left circumflex) grafting and either a VG or an AG to the right coronary system. RESULTS: Of 1691 patients, 983 received a VG and 708 received an AG to the right coronary system: 387 gastroepiploic arteries and 321 internal thoracic artery grafts. The median follow-up was 15.7 ± 0.32 years. For the VG and AG groups, early mortality (1.6% for VG and 1.3% for AG, P = .55) and other early adverse outcomes did not differ. Long-term (up to 20 years) survival was similar (34.1% ± 3.4% for VG vs 36.0% ±2% for AG, P = .86). In multivariable analysis, VG to the right coronary artery was not found to be a predictor of inferior survival (hazard ratio: 0.99, 95% confidence interval 0.836-1.194, P = .99). Comparing 2 propensity-matched groups of 349 pairs with a VG or an AG, and accounting for the severity of the right coronary lesion, did not demonstrate differences in early outcome or late survival between the groups. CONCLUSIONS: Early outcomes and long-term survival were comparable among patients who received left-sided bilateral internal thoracic artery revascularization, between various graft types to the right coronary system.

[A Case of Laparoscopic Gastrectomy for Gastric Cancer Occurring after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery].

We present a case of 72-year-old man who was diagnosed with gastric cancer that occurred after coronary artery bypass grafting(CABG)with the right gastroepiploic artery(RGEA). Gastrointestinal endoscopy revealed a 0-Ⅱc lesion at the posterior wall of gastric angle, and diagnosis was cStage Ⅰ(T2N0M0). Cardiac computed-tomography showed an occlusion of the RGEA graft, suggesting that the RGEA graft could be ligated and dissected. Coronary angiography showed no severe stenosis of the right coronary artery, suggesting that coronary revascularization was not necessary. He underwent laparoscopic distal gastrectomy with D2 lymph node dissection. During the operation, the RGEA graft was dissected after clamp test for 20 minutes to confirm no cardiac event. In such cases, it is crucial to consider whether it is possible or not to dissect the RGEA graft and whether to restore the coronary flow with preoperative meticulous examination.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

BACKGROUND AND AIM OF THE STUDY: Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). METHODS: Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. RESULTS: The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. CONCLUSIONS: Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

Hemoperitoneum due to a ruptured right gastroepiploic artery following non-interventional endoscopic ultrasonography: a case report.

Endoscopic ultrasonography has become a routine procedure in clinical practice and is widely accepted as a safe procedure. Previous studies have reported that severe bleeding rarely occurs even when performing fine-needle aspiration biopsy. Severe hemorrhage following non-interventional endoscopic ultrasonography has never been reported. We herein report a case of hemorrhagic shock due to hemoperitoneum caused by a ruptured right gastroepiploic artery consequent to a diagnostic endoscopic ultrasonography. The patient was administered two antithrombotic agents. An extensive diagnostic workup contributed to the correct diagnosis, which led to a successful treatment by transcatheter arterial embolization. Endoscopists should be aware of this rare, but potentially fatal, adverse event of endoscopic ultrasonography.