Single-Admission, Staged Restoration of Gastrointestinal Continuity After Right Gastroepiploic Artery Damage.

A case of iatrogenic right gastroepiploic artery injury during laparoscopic transhiatal esophagectomy is reported. This case report describes microvascular repair of the right gastroepiploic artery and vein. Subsequent intraoperative decision making with regard to a staged, single-admission successful esophagectomy is discussed. In this case of a single-admission, staged esophagectomy, the gastric conduit was be preserved after transection of the right gastroepiploic artery and vein.

A very rare cause of retroperitoneal bleeding in young patients: do not forget the occurrence of a ruptured left gastroepiploic artery aneurysm!

Visceral artery aneurysms represent a very rare condition. The affected patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on imaging. In this setting, gastric and gastroepiploic aneurysms account for only about 4% of all the splancnic aneurysms. Since ruptured visceral aneurysms present a high mortality, a prompt and adequate (surgical or radiological interventional) treatment is mandatory. Due to the difficulty in achieving an adequate transcatheter access in some cases the emergency laparotomy may represent the only chance for the recover of the affected patients. We report two cases of ruptured left gastroepiploic aneurysms occurred in two young male patients, treated respectively with emergency laparotomy and laparoscopy.

Abdominal surgery for gastric cancer following coronary artery bypass grafting using an in situ right gastroepiploic artery graft.

BACKGROUND: The right gastroepiploic artery (RGEA) is often used for coronary artery bypass grafting (CABG) in Japan. As gastric cancer has a high prevalence in many Asian countries, we investigated problems with surgery for gastric cancer after CABG using the RGEA. METHODS: A total of 860 patients underwent CABG using the RGEA between January 1997 and December 2006. Of these, 13 patients underwent surgery for gastric cancer after CABG. In all cases, the RGEA was harvested by the skeletonization technique, and an antegastric route was used for the anastomosis. RESULTS: Dissection for the No. 6 lymph node was not performed in all cases because of the risk of graft injury. Graft injury during gastric surgery occurred in one patient and post-operative ventricular fibrillation (VF) was observed in two patients. One case of hospital death due to VF and two cases of remote death were encountered. CONCLUSIONS: In planning a resection for gastric cancer following a CABG with a patent RGEA graft, the potential for graft injury must be anticipated. In advanced stages of gastric cancer when the RGEA needs to be resected to dissect the No.6 lymph node, a pre-operative percutaneous coronary intervention or a reoperative CABG may be indicated.

Abrupt occlusion of right gastroepiploic artery as an angiographic evidence of gastrointestinal hemorrhage

Angiography plays an important role in both diagnosis and treatment of gastrointestinal (GI) bleeding; however, the sensitivity is low for diagnosis. We report a case of a 38-year-old woman who presented with recurrent upper GI bleeding following central pancreatectomy. Multiple selective arteriograms failed to reveal any active bleeding or other common signs of bleeding. There was an abrupt occlusion of the right gastroepiploic artery initially interpreted to be a surgical ligation. Upon direct superselective injection near the occlusion, an area of frank contrast extravasation was demonstrated immediately beyond the occlusion. The underlying vessel was embolized with n-butyl cyanoacrylate without recurrent bleeding up to 3-month follow-up (AU)

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Management of intraoperative hemorrhage during NOTES: a prospective, randomized comparison.

BACKGROUND: The optimal strategy to manage intraoperative hemorrhage during NOTES is unknown. A randomized comparison of three instruments for hemorrhage control was performed [prototype endoscopic bipolar hemostasis forceps (BELA) vs. prototype endoscopic clip (E-CLIP) applier versus laparoscopic clip (L-CLIP) applier]. METHODS: A hybrid transvaginal NOTES model in swine was used, with hemorrhage induced in either the gastroepiploic (GE) arteriovenous bundle (vessel diameter ~3 mm) or in distal mesenteric vessels (vessel diameter ~1-2 mm). Hemostasis was attempted three times per vessel using each instrument in a randomized order. Full laparoscopic salvage was performed if hemorrhage persisted beyond 10 min. Outcomes included primary success rate (PS), primary hemostasis time (PHT), number of device applications (DA), and overall hemostasis time (OHT, including salvage). RESULTS: Seventy hemostasis attempts were made in 12 swine. PS was 42-67 % for the GE vessels, with no difference between instruments. PHT and OHT also were similar between instruments, with the BELA and L-CLIP having a higher number of DA. PS was (80-100 %) in mesenteric vessels, with the BELA and L-CLIP resulting in a shorter mean PHT compared with the E-CLIP. CONCLUSIONS: All three instruments had similar effectiveness in achieving primary hemostasis during hybrid NOTES. Management of small vessel bleeding (1-2 mm) in a porcine model is effective using all three instruments but may be most efficient with the BELA or L-CLIP. Large vessel bleeding (≥3 mm) may be best managed by adding laparoscopic ports for assistance while maintaining a low threshold for conversion to full laparoscopy.