Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis.

BACKGROUND: Leakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery. METHOD: Embase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A "random-effects model" was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I2-test. RESULTS: From the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7-24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42-3.34)), celiac axis (OR 1.62(CI 1.15-2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27-5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I2 = 71% and 59%, respectively) but not for the right branches of the celiac axis (I2 = 0%). CONCLUSION: This meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.

Cadaver Study of Combined Neurovascular Sensate Flaps to Create Vaginal Erogenous Sensation During Male-to-Female Genital Confirmation Surgery: The Pedicle "O" Flap.

PURPOSE: The lack of erogenous sensitivity in the neovagina is one of the major shortcomings for patients undergoing male-to-female genital confirmation surgery. Remnant fibers of the dorsal nerve of the penis (DNP) after clitroplasty can potentially be used for a second neurovascular pedicle flap for intravaginal erogenous sensation. METHODS: An anatomic dissection of the DNP was performed in 10 male frozen pelvises to identify major trunks and their branches. Lateral branches of DNP were preserved for a sensate "O" pedicle flap for the vagina. The number of main branches in the lateral dorsal aspect of the penis was calculated to ensure sufficient erogenous innervation to the vagina. Cross sections of the penis were used for histological analysis. Optimal width and length of the new sensate flap were described. RESULTS: There were 1, 2, and 3 main branches in the lateral compartment in 2 (20%), 6 (30.7%), and 2 (42.8%) cadavers, respectively. A sensate pedicle flap from the lateral aspect of the glans penis with a mean width of 1.14 cm (range, 0.9-1.28 cm) ensured at least one main branch of the DNP for erogenous sensitivity of the vagina. This sensate vaginal flap and its neurovascular pedicle had a mean length of 9.8 cm (range, 8.7-10.3 cm) allowing its inset into the anterior vaginal canal. CONCLUSION: Lateral branches of the DNP can be preserved for a pedicle sensate flap to the vagina, which can provide patients with an erogenous vaginal "spot" during male-to-female confirmation surgery.

Long-term outcome and quality of life after supercharged jejunal interposition for oesophageal replacement.

BACKGROUND: The consequences of major conduit necrosis following oesophagectomy are devastating. Jejunal interposition with vascular supercharging is an alternative reconstructive method if colon is unavailable. Aims of this study were to review the long-term outcome and quality of life of patients undergoing this surgery in our tertiary unit. METHODS: Patients undergoing oesophageal reconstruction with supercharged jejunum were identified and retrospective review of hospital notes performed. Each patient was then interviewed for follow up data and quality of life assessment using the EORTC QLQ-C30 questionnaire. RESULTS: Six patients (5 men) (median age 59 years (range 34-72) underwent supercharged pedicled jejunal (SPJ) interposition from May 2005-August 2010. Indications for surgery were loss of both gastric and colonic conduits following surgery for oesophageal cancer (n = 4), loss of gastric conduit and previous colectomy (n = 1) and lastly, gastric and colonic infarction in a strangulated paraoesophageal hernia (n = 1). Median time to reconstruction was 12 months [6-15 range]. There were no in-hospital deaths. Median postoperative stay was 46 days [13-118]. Three patients required surgical re-intervention for leak, sepsis and reflux, respectively. Median follow up was 6.5 years [range 7-102 months]. One patient died seven months following surgery due to respiratory complications. On follow up, 5 patients have an enteral diet without supplemental nutrition, maintaining weight and good quality of life scores. CONCLUSIONS: Supercharged jejunal interposition is a suitable alternative conduit for delayed oesophageal replacement in patients with otherwise limited reconstructive options. Good functional outcomes can be achieved despite formidable technical challenges in this group.

[Lower limb omental implantation in patients with obliterative thrombangiitis].

The experience of 34 operations of omental implantation to the patients with the critical lower limb ischemia due to the obliterative thrombangiitis was analyzed. 5 patients had the procedure on the both limbs simultaneously. The operative technique had been thoroughly described in the article. The procedure, being accomplished according to the certain standards, proved to be extremely effective.

The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy.

BACKGROUND: Gastric tube necrosis is a major cause of anastomotic leak after esophagectomy. A correlation has been shown between reduced flux at the anastomotic end of the gastric tube and anastomotic leaks. METHODS: We prospectively studied the effect of intraoperative thoracic epidural bupivacaine and subsequent adrenaline infusion on hemodynamics and flux in the gastric tube. RESULTS: Administering the epidural bolus significantly decreased flux at the anastomotic end of the gastric tube (P < 0.01). Gastric flux was returned to baseline by an adrenaline infusion. CONCLUSIONS: The administration of a thoracic epidural bolus may decrease flux at the anastomotic end of the gastric tube.

Transient bloodletting of the short gastric vein in the reconstructed gastric tube improves gastric microcirculation during esophagectomy.

BACKGROUND: The reasons for anastomotic leakage in esophago-gastrostomy have been proposed to be poor arterial inflow and insufficient venous drainage at the anastomotic site. In order to improve the congestive status, we developed a novel and easy surgical procedure of transient bloodletting from the short gastric vein after making a gastric tube during esophagectomy, and evaluated tissue blood flow. METHODS: Patients with esophageal cancer, who had received transthoracic esophagectomy and gastric tube reconstruction with intrathoracic anastomosis, were enrolled. After making a slender gastric tube, transient bloodletting from the short gastric vein at the most cardiac site was performed for 30 minutes. The tissue blood flow of the proximal end of the gastric tube was measured using a laser Doppler flowmeter, and was compared in the bloodletting group (n = 68) and the control group without bloodletting (n = 8). RESULTS: In the bloodletting group, tissue blood flow 5 minutes after the start of bloodletting was markedly increased in comparison to that before bloodletting (9.5 +/- 4.9 ml/min/100 g vs. 24.1 +/- 5.9 ml/min/100 g). The elevated levels of tissue blood flow remained at almost constant levels after ceasing bloodletting and lasted until esophago-gastrostomy (20.1 +/- 3.9 ml/min/100 g). On the contrary, in the control group without bloodletting, tissue blood flows were marginally increased following construction of a gastric tube, but the changes did not reach significant levels. When the tissue blood flow just before esophago-gastrostomy was compared in the bloodletting and control groups, the flows in the bloodletting group were significantly more elevated than those in the control group (20.1 +/- 3.9 vs. 15.2 +/- 4.9 ml/min/100 g). CONCLUSIONS: Transient bloodletting of the short gastric vein in the gastric tube during esophagectomy may improve the microcirculation of the oral side of the gastric tube.

The width of a gastric tube has no impact on outcome after esophagectomy.

BACKGROUND: We evaluated the impact of the size of gastric tubes on tissue blood flow of the anastomotic site, the frequency of leakage and the postoperative nutritional status. METHODS: Forty-four patients were randomly allocated to either reconstruction using subtotal stomach (n = 22) or to reconstruction using slender gastric tube (n = 22) after esophagectomy. The tissue blood flow at the anastomotic site was measured. The postoperative nutritional status of 17 patients without recurrence was examined. Possible correlations between the type of esophageal substitute and the tendency to leakage as well as postoperative nutritional status were examined. RESULTS: There was no significant difference in the tissue blood and the frequency of leakage between the types of gastric tubes. There was no significant difference noted between the two in the postoperative nutritional status at 6 and 12 months after operation. CONCLUSIONS: The width of gastric tube has no impact on tissue blood flow, the frequency of leakage, and the postoperative nutritional status after esophagectomy.

Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy.

Anastomotic insufficiency is considered to be one of the most serious complications associated with esophageal reconstruction. The purposes of this study were to identify (1) the relationship between anastomotic insufficiency and tissue blood flow (TBF) in the gastric tube in the perioperative period, and (2) the effects of intravenous prostaglandin E1 (PGE1) on TBF in the gastric tube. The study group consisted of 44 patients who were to undergo esophagectomy for esophageal cancer. Intraoperative and postoperative TBF on the serosal side of the gastric tube were measured by laser-Doppler tissue blood flowmetry. The TBF of the Leakage(+) group (n = 5) was poorer than that of the Leakage(?) group (n = 39) during the intraoperative and postoperative periods. There was a significant difference in TBF between the two groups at postoperative day (POD) 3. There was a tendency in the PGE1(+) group (n = 18) to exhibit richer blood flow through the anastomosis than the PGE1(?) group (n = 26), intraoperatively, but the difference was not significant. Two of five Leakage(+) cases were also in the PGE1(+) group. There was no relationship between intraoperative medication with PGE1 and incidence of leakage. The TBF of three-field lymph node dissection and reconstruction of the retrosternal route group (n = 21) was poorer than that of the two-field lymph-node dissection and reconstruction of the posterior mediastinal route group (n = 23). The TBF in the gastric tube after esophagectomy may be a predictor of anastomotic insufficiency. However, PGE1 treatment in the intraoperative period alone is not effective in preventing anastomotic insufficiency.

Organ-preserving resection of the gastroesophageal junction and substitution with a gastric corpus rotation tube: an experimental study.

Premalignant lesions of the gastroesophageal junction are treated conservatively or by antireflux surgical procedures. We describe a novel technique that replaces the distal esophagus after resection of the gastroesophageal junction. After resection of the gastroesophageal junction, 16 pigs were divided into two groups. In group 1 (n = 9) the gastroesophageal junction was replaced with a 3 cm wide horizontal gastric corpus tube, pedicled at the lesser curvature. In group 2 (n = 7) the tube was pedicled at the greater curvature. Tube length, volume, and compliance of the gastric remnant and blood flow in the tube (by laser Doppler flowmetry given in perfusion units [PU]) were measured before and after tube formation and 2 weeks postoperatively. Group 1 tubes were 9.5 +/- 1. 5 cm long and group 2 tubes were 8.2 +/- 0.7 cm long. Tube formation decreased volume and compliance of the gastric remnant. After tube formation, blood flow at the tip of the tube decreased from 254 PU to 64 +/- 22 PU (group 1) and 87 +/- 36 PU (group 2). Volume, compliance, and blood flow returned to baseline values 2 weeks postoperatively. No anastomotic leakage was found on postmortem examination. Horizontal gastric corpus tubes might offer an alternative to replace the distal esophagus and proximal stomach after resection of premalignant lesions of the gastroesophageal junction.

Revascularization using the short gastric vessels of the gastric tube after subtotal esophagectomy for intrathoracic esophageal carcinoma.

BACKGROUND: Maintaining sufficient blood flow to the substitutive organ after esophagectomy is essential to decrease the risk of anastomotic leakage. STUDY DESIGN: Forty-one patients underwent subtotal esophagectomy for intrathoracic esophageal carcinoma and reconstruction using the gastric tube. Additional vascular anastomosis between the short gastric vessels and the vessels in the neck was performed in 15 patients. Tissue blood flow was measured by laser Doppler flowmetry before and after vascular anastomosis. The incidence of anastomotic leakage in the revascularization group was compared with that in the remaining 26 patients. RESULTS: Venous anastomosis was performed in 14 patients and arterial anastomosis in 9. There was a significant increase in tissue blood flow after venous anastomosis alone (mean percent increase: 36%; p < 0.01), and after arterial and venous anastomoses (mean percent increase: 108%; p < 0.01). No anastomotic leakage was observed in the revascularization group; six patients (23.1%) in the control group had leakage (p < 0.05). Patients in the revascularization group started taking a meal 10.0 +/- 0.4 days postoperatively, compared with 15.1 +/- 1.8 days in the control group (p < 0.05). CONCLUSIONS: Additional vascular anastomosis in esophageal reconstruction after subtotal esophagectomy achieved good results. This procedure can reduce the risk of anastomotic leakage and may be useful for esophageal reconstruction.

Additional microvascular anastomosis in reconstruction after total esophagectomy for cervical esophageal carcinoma.

BACKGROUND: Maintaining sufficient blood flow to the substitute organ after total esophagectomy is essential for decreasing the risk of anastomotic leakage. Additional venous, or arterial and venous, anastomoses between the vessels of the gastric tube and the vessels in the neck after total esophagectomy are described for 11 patients with cervical esophageal carcinoma. METHODS: The tissue blood flow was measured by laser Doppler flowmetry before and after anastomosis. Venous anastomosis was performed for all 11 patients, and arterial anastomosis was added for 7 patients. RESULTS: A significant increase in tissue blood flow was observed after venous anastomosis alone (mean, 19%; P < 0.05) and after arterial and venous anastomoses (mean 43%; P < 0.01). There was no anastomotic leakage or hospital death. CONCLUSIONS: This procedure may reduce the risk of anastomotic leakage especially in the case of pharyngogastrostomy following total esophagectomy.