Role of indocyanine green fluorescence imaging for evaluating blood supply in the gastric conduit via the substernal route after McKeown minimally invasive esophagectomy.

BACKGROUND: Anastomotic leakage (AL) is a determining factor of morbidity and mortality after esophagectomy. Adequate perfusion of the gastric conduit is crucial for AL prevention. This study aimed to determine whether intraoperative angiography using indocyanine green (ICG) fluorescence improves the incidence of AL after McKeown minimally invasive esophagectomy (MIE) with gastric conduit via the substernal route (SR). METHODS: This retrospective cohort study included 120 patients who underwent MIE with gastric conduit via SR for esophageal cancer between February 2019 and April 2023. Of 120 patients, 88 experienced intraoperative angiography using ICG (ICG group), and 32 patients experienced intraoperative angiography without ICG (no-ICG group). Baseline characteristics and operative outcomes, including AL as the main concern, were compared between the 2 groups. In addition, the outcomes among patients in the ICG group with different levels of fluorescence intensity were compared. RESULTS: The ICG and no-ICG groups were comparable in baseline characteristics and operative outcomes. There was no significant difference between the 2 groups regarding the rate of AL (31.0% vs 37.5%; P = .505), median dates of AL (9 vs 9 days; P = .810), and severity of AL (88.9%, 11.11%, and 0.0% vs 66.7%, 16.7%, and 16.7% for grades I, II, and III, respectively; P = .074). Patients in the ICG group with lower intensity of ICG had higher rates of leakage (24.6%, 39.3%, and 100% in levels I, II, and III of ICG intensity, respectively; P = .04). CONCLUSION: The use of ICG did not seem to reduce the rate of AL. However, abnormal intensity of ICG fluorescence was associated with a higher rate of AL, which implies a predictive potential.

Blood flow evaluation of reconstructed gastric tube in esophageal surgery using near-infrared imaging and retrospective time-intensity curve analysis.

PURPOSE: Near-infrared fluorescence imaging using indocyanine green (ICG-NIFI) can visualize a blood flow in reconstructed gastric tube; however, it depends on surgeon's visual assessment. The aim of this study was to re-analyze the ICG-NIFI data by an evaluator independent from the surgeon and feasibility of creating the time-intensity curve (TIC). METHODS: We retrospectively reviewed 97 patients who underwent esophageal surgery with gastric tube reconstruction between January 2017 and November 2022. From the stored ICG videos, fluorescence intensity was examined in the four regions of interest (ROIs), which was set around the planned anastomosis site on the elevated gastric tube. After creation the TICs using the OpenCV library, we measured the intensity starting point and time constant and assessed the correlation between the anastomotic leakage. RESULTS: Postoperative leakage occurred for 12 patients. The leakage group had significantly lack of blood flow continuity between the right and left gastroepiploic arteries (75.0% vs. 22.4%; P < 0.001) and tended to have slower ICG visualization time assessed by the surgeon's eyes (40 vs. 32 s; P = 0.066). TIC could create in 65 cases. Intensity starting point at all ROIs was faster than the surgeon's assessment. The leakage group tended to have slower intensity starting point at ROI 3 compared to those in the non-leakage group (22.5 vs. 19.0 s; P = 0.087). CONCLUSION: A TIC analysis of ICG-NIFI by an independent evaluator was able to quantify the fluorescence intensity changes that the surgeon had visually determined.

Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis.

BACKGROUND: Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE: Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS: Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS: Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS: Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.

[The first experience of fluorescent angiography with indocyanine green in primary esophagoplasty with gastric conduit in patients with malignant tumors of the esophagus]. / Pervyi opyt flyuorestsentnoi angiografii s indotsianinom zelenym pri pervichnoi ezofagoplastike zheludochnym steblem u bol'nykh so zlokachestvennymi opukholyami pishchevoda.

OBJECTIVE: To evaluate the possibilities of intraoperative indocyanine green fluorescein angiography (ICG technology) in primary esophagoplasty by gastric conduit in patients with malignant tumors of the esophagus. MATERIAL AND METHODS: The study included 74 patients. Depending on the localization of the tumor in the esophagus, a Lewis-type or McKeown-type operation was performed. The retrospective group (surgery without the use of ICG technology) included 53 patients who underwent surgery from 2015 to 2020 years.The prospective group (surgery with the use ICG technology) included 21 patients operated on from 2021 to 2023 years. ICG technology was used to assess microcirculation in the gastric conduit during esophagoplasty, as well as to identify the right gastroepiploic artery. RESULTS: The ICG fluorescein angiography technique for assessing microcirculation in the gastric conduit was a simple and easily reproducible procedure. Perfusion of the gastric conduit was regarded as satisfactory in 16 (76%) cases, unsatisfactory in 5 (24%) cases, which required resection of the distal part of the conduit. All cases of poor perfusion were in patients with narrow gastric conduit and neck anastomosis location (McKeown-type operation). Anastomotic leakages occurred in 8 (15%) patients in the retrospective group, 4 (19%) patients in the prospective group (p>0.05). In 4 out of 5 cases of poor gastric conduit perfusion, anastomotic leaks occurred. Immediate postoperative results in the compared groups were also comparable. The use of ICG technology in 5 (45%) cases out of 11, when laparoscopic mobilization of the stomach was performed, helped to visualize the right gastroepiploic artery, which is the main source of blood supply to the formed gastric conduit. The use of ICG technology in 3 patients with a compromised gastrostomy stomach demonstrated the absence of significant microcirculation disorders in the stomach wall. CONCLUSION: The first experience of using fluorescein angiography with ICG in primary esophagoplasty by gastric conduit in patients with malignant tumors of the esophagus demonstrated the safety, simplicity and availability of this technique. An objective assessment of the effectiveness of the application of ICG technology requires the accumulation of experience.

[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.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy induces gastric neo-angiogenesis.

BACKGROUND: The risk of an anastomotic leakage (AL) following Ivor-Lewis esophagectomy is increased in patients with calcifications of the aorta or a stenosis of the celiac trunc. Ischemic conditioning (ISCON) of the gastric conduit prior to esophagectomy is supposed to improve gastric vascularization at the anastomotic site. The prospective ISCON trial was conducted to proof the safety and feasibility of this strategy with partial gastric devascularization 14 days before esophagectomy in esophageal cancer patients with a compromised vascular status. This work reports the results from a translational project of the ISCON trial aimed to investigate variables of neo-angiogenesis. METHODS: Twenty esophageal cancer patients scheduled for esophagectomy were included in the ISCON trial. Serum samples (n = 11) were collected for measurement of biomarkers and biopsies (n = 12) of the gastric fundus were taken before and after ISCON of the gastric conduit. Serum samples were analyzed including 62 different cytokines. Vascularization of the gastric mucosa was assessed on paraffin-embedded sections stained against CD34 to detect the degree of microvascular density and vessel size. RESULTS: Between November 2019 and January 2022 patients were included in the ISCON Trial. While serum samples showed no differences regarding cytokine levels before and after ISCON biopsies of the gastric mucosa demonstrated a significant increase in microvascular density after ISCON as compared to the corresponding gastric sample before the intervention. CONCLUSION: The data prove that ISCON of the gastric conduit as esophageal substitute induces significant neo-angiogenesis in the gastric fundus which is considered as surrogate of an improved vascularization at the anastomotic site.

Balancing Safety and Efficacy to Determine the Most Suitable Size of Imaging-Visible Embolic Microspheres for Bariatric Arterial Embolization in a Preclinical Model.

OBJECTIVES: To identify the most suitable size of imaging-visible embolic agents with balanced safety and efficacy for bariatric arterial embolization (BAE) in a preclinical model. MATERIALS AND METHODS: Twenty-seven pigs were divided into 3 cohorts. In Cohort I, 16 pigs were randomized to receive (n = 4 each) 40-100-µm microspheres in 1 or 2 fundal arteries, 70-340-µm radiopaque microspheres in 2 fundal arteries, or saline. In Cohort II, 3 pigs underwent renal arterial embolization with either custom-made 100-200-µm, 200-250-µm, 200-300-µm, or 300-400-µm radiopaque microspheres or Bead Block 300-500 µm with microsphere distribution assessed histologically. In Cohort III, 8 pigs underwent BAE in 2 fundal arteries with tailored 100-200-µm radiopaque microspheres (n = 5) or saline (n = 3). RESULTS: In Cohort I, no significant differences in weight or ghrelin expression were observed between BAE and control animals. Moderate-to-severe gastric ulcerations were noted in all BAE animals. In Cohort II, renal embolization with 100-200-µm microspheres occluded vessels with a mean diameter of 139 µm ± 31, which is within the lower range of actual diameters of Bead Block 300-500 µm. In Cohort III, BAE with 100-200-µm microspheres resulted in significantly lower weight gain (42.3% ± 5.7% vs 51.6% ± 2.9% at 8 weeks; P = .04), fundal ghrelin cell density (16.1 ± 6.7 vs 23.6 ± 12.6; P = .045), and plasma ghrelin levels (1,709 pg/mL ± 172 vs 4,343 pg/mL ± 1,555; P < .01) compared with controls and superficial gastric ulcers (5/5). CONCLUSIONS: In this preclinical model, tailored 100-200-µm microspheres were shown to be most suitable for BAE in terms of safety and efficacy.

Laparoscopic ischemic conditioning prior esophagectomy in selected patients: the ISCON trial.

Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14 days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12-18 days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45 minutes (range: 25-230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2 days (range: 2-4 days). Esophagectomy was completed in all patients after a median of 14 days (range: 12-28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.

Variations in the origin of the right gastric artery: a systematic review and meta-analysis.

PURPOSE: The right gastric artery (RGA) supplies the lesser curvature of the stomach. The prevalence of variations in RGA origins can be of interests to students, surgeons, and radiologists who wish to increase their understanding of this vessel. The aim of this study was to perform a systematic review and meta-analysis on the origin of the RGA. METHODS: The PRISMA 2020 checklist was followed. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. There were no constraints based on language or publication status. Database search, data extraction and risk of bias assessment were performed independently by two authors. A random-effects meta-analysis of the prevalence of different RGA origins was conducted. RESULTS: A total of 9084 records were screened in the initial search. Fifteen studies were included, assessing 1971 right gastric arteries. The RGA arose most frequently from the Proper Hepatic Artery (PHA), with a pooled prevalence of 53.6% (95% CI 44.5-60.8%), followed by the Left Hepatic Artery (LHA) with a pooled prevalence of 25.9% (95% CI 18.6-32.8%), and the Gastroduodenal Artery (GDA) with a pooled prevalence of 8.89% (95% CI 4.62-13.9%). Less common origins were the Common Hepatic Artery (CHA) (6.86%, 95% CI 3.15-11.5%), the Right Hepatic Artery (RHA) (3.43%, 95% CI 0.93-7.04%), and Middle Hepatic Artery (MHA) (1.31%, 95% CI 0-3.44%). CONCLUSIONS: This meta-analysis provides an accurate estimate of the prevalence of different RGA origins. Anatomical knowledge combined with pre-operative planning and imaging can prevent iatrogenic injury during surgery.

Near-infrared fluorescence imaging with indocyanine green to assess the blood supply of the reconstructed gastric conduit to reduce anastomotic leakage after esophagectomy: a literature review.

The blood supply of the right gastroepiploic artery after esophagectomy with gastric tube reconstruction is essential for avoiding anastomotic leakage. Near-infrared fluorescence (NIRF) imaging with indocyanine green is widely used to assess the blood supply because it can visualize it in real-time during navigation surgery. However, there is no established protocol for this modality. One reason for this lack of protocol is that NIRF provides subjective information. This study aimed to evaluate NIRF quantification. We conducted a literature review of risk factors for anastomotic leakage after esophagectomy, NIRF procedures, NIRF quantification, and new methods to compensate for NIRF limitations. Major methods for the quantification of NIRF include measuring the blood flow speed, visualization time, and fluorescence intensity. The cutoff value for the blood flow speed is 2.07 cm/s, and that for the visualization time is 30-90 s. Although the time-intensity curve provided patterns of change in the blood flow, it did not show an association with anastomotic leakage. However, to compensate for the limitations of NIRF, new devices have been reported that can assess tissue oxygenation perfusion, organ hemoglobin concentration, and microcirculation.

Predictive impact of the thoracic inlet space on ICG fluorescence blood flow speed in the gastric conduit wall and anastomotic leakage after esophagectomy.

PURPOSE: The thoracic inlet space might influence the blood vessel perfusion in the gastric conduit. The purpose of this study was to clarify the impacts of the thoracic inlet space on blood vessel perfusion in the gastric conduit and anastomotic leakage after esophagectomy. METHODS: One hundred and forty-two esophageal cancer patients underwent esophagectomy followed by gastric conduit reconstruction via the retrosternal route. The blood flow speed in the gastric conduit was measured using indocyanine green fluorescence before and after reconstruction. Parameters at the thoracic inlet space were measured using CT. We then investigated the correlation between these two parameters and whether they could predict anastomotic leakage after esophagectomy. RESULTS: Blood flow speed in the gastric conduit was slower after reconstruction than before reconstruction (P < 0.001). The incidence of anastomotic leakage (n = 23) was higher among patients with a delayed blood flow speed before reconstruction (n = 27) than among those with a non-delayed blood flow speed before reconstruction (n = 115) (P < 0.001). Among the patients with a non-delayed blood flow speed before reconstruction, the thoracic inlet area (TIA, sternum-tracheal distance × clavicle head distance) was positively correlated with the blood flow speed after reconstruction (P = 0.023) and was identified as an independent predictor of anastomotic leakage (P < 0.001). CONCLUSION: A narrow TIA was associated with a delayed blood flow speed in the gastric conduit after reconstruction and was capable of predicting anastomotic leakage in the patients with a non-delayed blood flow speed before reconstruction.

Wider Gastric Conduit Morphology Is Associated with Improved Blood Flow During Esophagectomy.

BACKGROUND: It remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy. METHODS: Patients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively. RESULTS: Three hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups. CONCLUSIONS: Conduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks.

Ulcer Scarring in the Gastric Conduit Is a Risk Factor for Anastomotic Leakage After Esophagectomy for Esophageal Cancer.

BACKGROUND: Anastomotic leakage (AL) is a serious complication after esophagectomy for esophageal cancer. The objective of this study was to identify the risk factors for AL. METHODS: Patients with esophageal cancer who underwent curative esophagectomy and cervical esophagogastric anastomosis between 2009 and 2019 (N = 346) and those between 2020 and 2022 (N = 17) were enrolled in the study to identify the risk factors for AL and the study to assess the association between the risk factors and blood flow in the gastric conduit evaluated by indocyanine green (ICG) fluorescence imaging, respectively. RESULTS: AL occurred in 17 out of 346 patients (4.9%). Peptic or endoscopic submucosal dissection (ESD) ulcer scars were independently associated with AL (OR 6.872, 95% CI 2.112-22.365) in addition to diabetes mellitus. The ulcer scars in the anterior/posterior gastric wall were more frequently observed in patients with AL than in those without AL (75.0% vs. 17.4%, P = 0.042). The median flow velocity of ICG fluorescence in the gastric conduits with the scars was significantly lower than in those without the scars (1.17 cm/s vs. 2.23 cm/s, P = 0.004). CONCLUSIONS: Peptic or ESD ulcer scarring is a risk factor for AL after esophagectomy in addition to diabetes mellitus. The scars in the anterior/posterior gastric wall are significantly associated with AL, impairing blood flow of the gastric conduit. Preventive interventions and careful postoperative management should be provided to minimize the risk and severity of AL in patients with these risk factors.

Conservative management of gastric pneumatosis following left gastric artery embolisation.

Gastric pneumatosis, the presence of air within the stomach wall, is a very rare occurrence with poor outcomes. One of the most common mechanisms for gastric pneumatosis is gastric ischaemia, also a rare entity. Although patients with gastric ischaemia may require surgical intervention, they can often be treated with conservative measures such as a proton pump inhibitor, broad-spectrum antibiotics, nasogastric tube decompression, fluid resuscitation and total parenteral nutrition. We report a rare case of gastric ischaemia and pneumatosis following therapeutic left gastric artery argon plasma coagulation that was treated with conservative measures.

ANATOMICAL VARIATIONS OF PORTAL VENOUS SYSTEM: IMPORTANCE IN SURGICAL CLINIC.

AIM: Knowledge of the portal system and its anatomical variations aids to prevent surgical adverse events. The portal vein is usually made by the confluence of the superior mesenteric and splenic veins, together with their main tributaries, the inferior mesenteric, left gastric, and pancreaticoduodenal veins; however, anatomical variations are frequent. This article presents a literature review regarding previously described anatomical variations of the portal venous system and their frequency. METHODS: A systematic review of primary studies was performed in the databases PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect, and Scopus. Databases were searched for the following key terms: Anatomy, Portal vein, Mesenteric vein, Formation, Variation, Variant anatomic, Splenomesenteric vein, Splenic vein tributaries, and Confluence. RESULTS: We identified 12 variants of the portal venous bed, representing different unions of the splenic vein, superior mesenteric vein, and inferior mesenteric vein. Thomson classification of the end of 19th century refers to the three most frequent variants, with type I as predominant (M=47%), followed by type III (M=27.8%) and type II (M=18.6%). CONCLUSION: Thomson classification of variants is the most well-known, accounting for over 90% of portal venous variant found in clinical practice, inasmuch as the sum of the three junctions are found in over 93% of the patients. Even though rarer and accounting for less than 7% of variants, the other nine reported variations will occasionally be found during many abdominal operations.

Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report.

BACKGROUND: The gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply. CASE PRESENTATION: A 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally. CONCLUSIONS: Oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.

The Features of Stomach Vascularisation Pattern and Their Impact on Oesophageal Reconstruction with a Gastric Pull-up.

Regardless of the reconstruction surgery used, the fundamental concepts of visceral reconstruction are based on the vascular support needed for the substituting graft. The vascular factor is the main element of any reconstruction technique, as an underlying condition for the visceral material stretch and, along with other factor, for the suture safety. In the case of the stomach, a consistent vascular flow and the minimal vascular anatomy variations are the first theoretical argument. A second argument is based on the intraparietal vascular network features allowing for supplementing visceral perfusion as the blood flow is stopped in one or more pediculi. Graft hypoperfusion is, however, a potential cause of failure, and the most frequently invoked complication is, therefore, a high risk of anastomosis fistulae. A series of modern techniques - arteriography data for the pre-operative vascular reconstruction or Doppler laser fluorometry intraoperative assessments, graft oximetry, laser speckle (spot) scan or the use of indocyanine green staining (ICG) - represent methods of early determination of the gastric graft perfusion/microperfusion quality used in reducing such risks. The doubts regarding the gastric perfusion mandate the use of vascular augmentation techniques. If such techniques are not used, the final outcome is uncertain and difficult to correct.

A novel imaging technology to assess oxygen saturation of the gastric conduit in thoracic esophagectomy.

BACKGROUND: Real-time evaluation of blood perfusion is important when selecting the site of anastomosis during thoracic esophagectomy. This study investigated a novel imaging technology that assesses tissue oxygen saturation (StO2) in the gastric conduit and examined its efficacy. METHODS: Fifty-one patients undergoing thoracic esophagectomy for esophageal cancer who underwent intraoperative StO2 endoscopic imaging to assess the gastric conduit for the optimal site of anastomosis were examined. Efficacy of oxygen saturation imaging and patient outcomes were analyzed. RESULTS: All 51 patients underwent esophagectomy without intraoperative problems. Mean StO2 in the gastric tube was highest at the pre-pylorus area and then gradually decreased proceeding toward the tip. StO2 was well preserved in areas supplied by the right gastroepiploic artery but low in other areas. Anastomotic sites were selected based on StO2 imaging and tension considerations; most were located within 3 cm of the end of the right gastroepiploic artery. Three patients developed postoperative anastomotic leakage (5.8%). Mean StO2 at the point of anastomosis was significantly lower in the patients who experienced leakage than in those who did not (P = 0.04). CONCLUSION: Intraoperative endoscopic StO2 imaging is useful in esophageal cancer patients undergoing thoracic esophagectomy to determine the optimal site for anastomosis to minimize the risk of anastomotic leakage.