Subtotal gastrectomy for gastric tube cancer after esophagectomy: a safe procedure preserving the proximal part of gastric tube based on intraoperative ICG blood flow evaluation

Pedunculated gastric tube with distal partial gastrectomy for esophageal reconstruction in synchronous or metachronous esophagectomy

While the stomach is commonly used as an esophageal substitute after esophagectomy, it may not be a viable option in some cases. One alternative for esophageal reconstruction is a pedunculated gastric tube with distal partial gastrectomy (PGT-DPG). However, no studies have comprehensively analyzed its efficacy. We retrospectively evaluated the clinical characteristics and surgical outcomes of patients who underwent PGT-DPG between 2011 and 2023, and reviewed previously published studies on the surgical outcomes of PGT-DPG. Among the nine patients in the current study, seven underwent PGT-DPG for gastric cancer; of which, five were performed concurrently with esophagectomy, while two were conducted following prior esophagectomy. Additionally, PGT-DPG was performed in two cases with benign gastric lesions. The major postoperative complications included pneumonia (two cases), anastomotic leakage (two cases), and recurrent laryngeal nerve paralysis (one case). No graft necrosis or mortality was observed. Our review of these cases, along with previously reported cases, indicated that PGT-DPG showed efficacy due to its availability for antral early gastric cancer, avoidance of bowel reconstruction, simplified technique, and improved cervical elevation. PGT-DPG is a valuable rescue option in cases in which gastric tube reconstruction is challenging. Therefore, esophageal surgeons should be well acquainted with this technique.

Long-Term Outcomes of the Treatment for Gastric Tube Cancer After Esophagectomy for Esophageal Cancer

BACKGROUND

The long-term outcomes of gastric tube cancer (GTC) are unclear. This study therefore aimed to clarify clinicopathologic features and the long-term outcomes of patients with GTC.

METHODS

The 25 patients who were diagnosed with GTC between April 2003 and December 2022 at our hospital were eligible for inclusion in this retrospective study, and this included 27 lesions. We retrospectively evaluated clinicopathologic factors based on hospital records.

RESULTS

In our cohort, 88% of incidences of GTC were located in the middle or lower gastric tube. As the treatment of GTC, we used endoscopic submucosal dissection, gastrectomy, chemoradiotherapy, chemotherapy, and best supportive care for 16 (59%), 6 (22%), 1 (4%), 1 (4%), and 3 (11%) lesions, respectively. Perforation after endoscopic submucosal dissection was observed in 6 of the 16 lesions. Partial gastric tube resection was performed for 3 patients and total gastric tube resection was performed for 3 patients. One patient who underwent total gastric tube resection died due to acute respiratory distress syndrome. In survival analysis, the 3-year overall survival rate was 52% and the 3-year disease-specific survival rate was 74%. Five patients (20%) died of aspiration pneumonia, 2 patients (8%) of another disease, and 1 patient (4%) of another type of cancer. According to multivariate analysis, independent prognostic factors for overall survival were cN status (HR, 18.021; P =0.004) and complication of aspiration pneumonia (HR, 8.373; P =0.004).

CONCLUSIONS

The occurrence of aspiration pneumonia and cN status were prognostic factors after the treatment for GTC. Assessment of dysphagia and surveillance after treatment for GTC are important to improve the prognosis.

Laparoscopic right gastroepiploic artery-sparing distal gastric tube resection with lymph node dissection for gastric tube cancer after esophagectomy: A novel surgical approach (with video)

INTRODUCTION

Total resection of the gastric tube with lymphadenectomy for advanced gastric tube cancer is highly invasive and associated with severe complications. Other surgical option, partial gastrectomy or wedge resection, is insufficient if lymph node metastasis is suspected. Therefore, a technique balancing invasiveness and curability is required.

MATERIALS AND SURGICAL TECHNIQUE

First, we laparoscopically peeled off adhesions of the gastric tube, gastric mesentery (including the right gastroepiploic artery/vein), pericardial membrane, and aorta, up to the planned resection line. Subsequently, we cut the infrapyloric and right gastric arteries at their roots and dissected No. 5 and No. 6 lymph nodes. We taped and spared the right gastroepiploic artery and vein and dissected the tissues including No. 4d lymph nodes. Finally, the gastric tube was cut using a linear stapler, and the remaining gastric tube was anastomosed to the jejunum with a circular stapler. The mean operative time for the three cases treated using this intervention was 729 min. The patients were discharged on postoperative day 8 or 9 without any complications. They all remained alive and recurrence-free.

DISCUSSION

This novel approach balances invasiveness and curability by leveraging the advantages of laparoscopy. The procedure was performed safely and reproducibly in three consecutive cases, providing another viable option for the treatment of gastric tube cancer.

Successful Robot-Assisted Surgery for Advanced Metachronous Cancer in a Gastric Conduit after Esophagectomy: A Case Report

The incidence of gastric tube cancers has increased due to improved survival rates in patients after esophagectomy. However, the optimal surgical approach for gastric tube cancer remains controversial. Here, we report the case of a 70-year-old man with advanced gastric cancer arising from a retrosternally placed gastric conduit, 12 years after thoracic esophagectomy for esophageal cancer. Total resection of the gastric conduit was performed with robotic assistance. Although the working space was limited, secure resection was possible. Continuous en bloc mobilization was achieved with neck dissection, and reconstruction was performed via the same retrosternal route using the ileocolon. The patient was discharged on the 14th postoperative day without any adverse events. Robot-assisted surgery can overcome the technical limitations of laparoscopic mediastinal surgery and has advantages such as improved ergonomics, comfort, and elimination of hand tremors, and therefore may be an option for future minimally invasive surgeries.

Preservation of remnant esophagus during total pharyngolaryngectomy in a patient with previous subtotal esophagectomy: a case report

Background

With the improved survival rate of patients with esophageal cancer, secondary cancers, including pharyngolaryngeal cancer, have become a problem. Phanryngolaryngeal cancer surgery often requires esophagogastric anastomosis resection in patients with a previous history of subtotal esophagectomy. Owing to adhesions, especially surrounding the esophagogastric anastomosis, caused by the initial surgery, the second surgery might cause postoperative complications.

Case presentation

A 65-year-old man was diagnosed with early stage esophageal squamous cell carcinoma and underwent endoscopic mucosal dissection. However, the histopathological depth of the tumor was pT1b, and additional treatment was required. After administration of the neoadjuvant chemotherapy, he underwent thoracoscopic esophagectomy and retrosternum reconstruction via a gastric tube (pT1N3M0 stage III). Eight months after the first surgery, tumor recurrences were observed at the anastomosis and left cervical lymph node. Definitive chemoradiotherapy was performed for the recurrences, and complete response was achieved. Seven months after chemoradiotherapy, he was diagnosed with hypopharyngeal squamous cell carcinoma in the right piriform fossa (cT2N2bM0 stage IVA), and salvage surgery was chosen as treatment. The surgical findings revealed strong adhesion around the remnant esophagus, which was difficult to dissect from surrounding tissue and was associated with a risk of breaking of the anastomosis. However, indocyanine green fluorescence imaging findings indicated sufficient blood flow to preserve the remnant esophagus, including the anastomosis, even after the interruption of blood flow from the proximal side of the esophagus by total pharyngolaryngectomy. Finally, approximately 4 cm of the remnant esophagus was preserved, and the free jejunum reconstruction with cervical vascular anastomosis was performed. Moreover, the patient was discharged without complications on postoperative day 38. After 10 months of the second surgery, a metastatic lymph node was observed in the right neck. Immune checkpoint inhibitors and chemotherapy were administered, and the patient is alive and under treatment 1.5 years after the second surgery.

Conclusions

Blood supply to the remnant cervical esophagus was thought to be from the gastric conduit over the anastomosis and surrounding capillaries. Thus, the preservation of the remnant esophagus can be considered in total pharyngolaryngectomy even after < 2 years of esophagectomy by blood flow evaluation using indocyanine green fluorescence.

Preservation of remnant esophagus during total pharyngolaryngectomy in a patient with previous subtotal esophagectomy: a case report

BACKGROUND

With the improved survival rate of patients with esophageal cancer, secondary cancers, including pharyngolaryngeal cancer, have become a problem. Phanryngolaryngeal cancer surgery often requires esophagogastric anastomosis resection in patients with a previous history of subtotal esophagectomy. Owing to adhesions, especially surrounding the esophagogastric anastomosis, caused by the initial surgery, the second surgery might cause postoperative complications.

CASE PRESENTATION

A 65-year-old man was diagnosed with early stage esophageal squamous cell carcinoma and underwent endoscopic mucosal dissection. However, the histopathological depth of the tumor was pT1b, and additional treatment was required. After administration of the neoadjuvant chemotherapy, he underwent thoracoscopic esophagectomy and retrosternum reconstruction via a gastric tube (pT1N3M0 stage III). Eight months after the first surgery, tumor recurrences were observed at the anastomosis and left cervical lymph node. Definitive chemoradiotherapy was performed for the recurrences, and complete response was achieved. Seven months after chemoradiotherapy, he was diagnosed with hypopharyngeal squamous cell carcinoma in the right piriform fossa (cT2N2bM0 stage IVA), and salvage surgery was chosen as treatment. The surgical findings revealed strong adhesion around the remnant esophagus, which was difficult to dissect from surrounding tissue and was associated with a risk of breaking of the anastomosis. However, indocyanine green fluorescence imaging findings indicated sufficient blood flow to preserve the remnant esophagus, including the anastomosis, even after the interruption of blood flow from the proximal side of the esophagus by total pharyngolaryngectomy. Finally, approximately 4 cm of the remnant esophagus was preserved, and the free jejunum reconstruction with cervical vascular anastomosis was performed. Moreover, the patient was discharged without complications on postoperative day 38. After 10 months of the second surgery, a metastatic lymph node was observed in the right neck. Immune checkpoint inhibitors and chemotherapy were administered, and the patient is alive and under treatment 1.5 years after the second surgery.

CONCLUSIONS

Blood supply to the remnant cervical esophagus was thought to be from the gastric conduit over the anastomosis and surrounding capillaries. Thus, the preservation of the remnant esophagus can be considered in total pharyngolaryngectomy even after < 2 years of esophagectomy by blood flow evaluation using indocyanine green fluorescence.

Distal gastric tube resection with preservation of the right gastroepiploic artery for gastric tube cancer: a case report

BACKGROUND

The incidence of gastric tube cancer is increasing because of improved survival rates in patients with esophageal cancer treated by esophagectomy. Total resection of the gastric tube is expected to be highly curative, but it is associated with a higher risk of severe postoperative complications. Herein we report a case of early gastric tube cancer that was successfully treated by distal gastric tube resection with preservation of the right gastroepiploic artery (RGEA).

CASE PRESENTATION

An 82-year-old man was diagnosed as having gastric tube cancer, B-12-O, Type 0-IIc, T1b, N0, M0, cStage IA (Japanese Classification of Gastric Carcinoma). Upper gastrointestinal endoscopy showed a Type 0-IIc lesion measuring 30 mm in length in the lower part of the gastric tube, and histopathological examination of biopsy specimens revealed the features of poorly differentiated adenocarcinoma. The primary lesion could not be identified by computed tomography, and there was no obvious lymph node metastasis or distant metastasis. Considering that total resection of the gastric tube would have been highly invasive and that the gastric tube cancer was at a relatively early stage, we performed distal gastric tube resection with preservation of the RGEA. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. There has been no recurrence during the 17 months of follow-up.

CONCLUSION

We successfully treated a patient with gastric tube cancer by distal gastric tube resection with preservation of the RGEA. This treatment strategy may be acceptable for patients with early gastric tube cancer without lymph node metastasis, considering the balance between the surgical invasiveness and curability of the tumor.

Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review

BACKGROUND

The development of esophago-bronchial fistula after esophagectomy and reconstruction using a posterior mediastinal gastric tube remains a rare complication associated with a high rate of mortality.

CASE PRESENTATION

A 63-year-old man with esophageal cancer underwent a thoracoscopic esophagectomy with two-field lymph node dissection and reconstruction via a gastric tube through the posterior mediastinal route. Postoperatively, the patient developed extensive pyothorax in the right lung due to port site bleeding and hematoma infection. Four months after surgery, he developed an esophago-left bronchial fistula due to ischemia of the cervical esophagus and severe reflux esophagitis at the site of the anastomosis. Because of respiratory failure due to the esophago-bronchial fistula and the history of extensive right pyothorax, right thoracotomy and left one-lung ventilation were thought to be impossible, so we decided to perform the surgery in three-step systematically. First, we inserted a decompression catheter and feeding tube into the gastric tube as a gastrostomy and expected neovascularization to develop from the wall of the gastric tube through the anastomosis after this procedure. Second, 14 months after esophagectomy, we constructed an esophagostomy after confirming blood flow in the distal side of the cervical esophagus via gastric tube using intraoperative indocyanine green-guided blood flow evaluation. In the final step, we closed the esophagostomy and performed a cervical esophago-jejunal anastomosis to restore esophageal continuity using a pedicle jejunum in a Roux-en-Y anastomosis via a subcutaneous route.

CONCLUSION

This three-step operation can be an effective procedure for patients with esophago-left bronchial fistula after esophagectomy, especially those with respiratory failure and difficulty in undergoing right thoracotomy with left one-lung ventilation.

Distal partial gastrectomy for gastric tube cancer with intraoperative blood flow evaluation using indocyanine green fluorescence

With recent advances in the treatment of esophageal cancer and long-term survival after esophagectomy, the number of gastric tube cancer (GTC) has been increasing. Total gastric tube resection with lymph node dissection is considered to be a radical treatment, but it causes high post-operative morbidity and mortality. We report an elderly patient with co-morbidities who developed pyloric obstruction due to GTC after esophagectomy with retrosternal reconstruction. The patient was treated using distal partial gastric tube resection (PGTR) and Roux-en-Y reconstruction with preservation of the right gastroepiploic artery and right gastric artery. Intraoperative blood flow visualization using indocyanine green (ICG) fluorescence demonstrated an irregular demarcation line at the distal side of the preserved gastric tube, indicating a safe surgical margin to completely remove the ischemic area. PGTR with intraoperative ICG evaluation of blood supply in the preserved gastric tube is a safe and less-invasive surgical option in patients with poor physiological condition.

Metachronous carcinoma of the gastric tube following tumour-associated oesophagectomy

INTRODUCTION

The prognosis of oesophageal carcinoma has improved during the last years. Thereby, the increasing survival has led to increasing occurrence of secondary gastric tube carcinoma (gastric conduit cancer, GTC) following oesophageal tumour resection.

MATERIAL AND PATIENTS

A literature review (EMBASE, PubMed), spanning the years 2000 to 2020, identified 342 patients worldwide with a GTC following tumour-related oesophagectomy, of which 306 patients could be included for further analysis.

RESULTS

The median age of 306 patients with GTC was 66.4 (39-80) years. 91.2% of patients (n = 279) were male. The median interval between oesophagectomy and GTC was 60.3 (4-236) months. 73.8% of patients (n = 226) were diagnosed as early cancer (EGC, T1) and 26.2% as advanced carcinoma (AGC, > T2; n = 80). Primary oesophagectomy was performed in 97.4% of patients (N = 298) for squamous cell carcinoma. AEG I carcinoma was present in only 5 patients (1.6%). In contrast, 99% (n = 303) of the GTC were found to be adenocarcinomas. One hundred eighty patients (58.8%) could be treated by endoscopic resection (ER). R0 resection was achieved in 82.8% (n = 149). The complication rate was 13.3% (n = 24) and the 30-day mortality 1.1% (n = 2) for ER. Eighty-three patients (27.1%) were treated surgically. These included 13 wedge resections, 25 partial resections and 45 total gastric graft resections with predominantly colon interposition. The R0 rate was 98.8% (n = 82). The postoperative morbidity was 24.1% (n = 20); the 90-day mortality was 6% (n = 5). In 43 patients (14%), palliative chemotherapy or radiotherapy or best supportive care took place. GTC diagnosed early in the EGC stage can be safely managed with ER. In cases of advanced GTC, surgical resection can be a potentially curative approach. Survival times of up to 120 months have been described after intervention for GTC.

Distal gastric tube resection with vascular preservation for gastric tube cancer: A case report and review of literature

BACKGROUND

Survival rates in patients with esophageal cancer undergoing esophagectomy have improved, but the prevalence of gastric tube cancer (GTC) has also increased. Total resection of the gastric tube with lymph node dissection is considered a radical treatment, but GTC surgery is more invasive and involves a higher risk of severe complications or death, particularly in elderly patients.

CASE SUMMARY

We report an elderly patient with early GTC that had invaded the duodenum who was successfully treated with resection of the distal gastric tube and Roux-en-Y (R-Y) reconstruction. The tumor was a type 0-IIc lesion with ulcer scars surrounding the pyloric ring. Endoscopic submucosal resection was not indicated because the primary lesion was submucosally invasive, was undifferentiated type, surrounded the pyloric ring, and had invaded the duodenum. Resection of distal gastric tube with R-Y reconstruction was safely performed, with preservation of the right gastroepiploic artery (RGEA) and right gastric artery (RGA).

CONCLUSION

Distal resection of the gastric tube with preservation of the RGEA and RGA is a good treatment option for elderly patients with cT1bN0 GTC in the lower part of the gastric tube.

Fluorescence Image-Based Evaluation of Gastric Tube Perfusion during Esophagogastrostomy

During esophagectomy and esophagogastrostomy, the prediction of anastomotic leakage relies on the operating surgeon's tactile or visual diagnosis. Therefore, anastomotic leaks are relatively unpredictable, and new intraoperative evaluation methods or tools are essential. A fluorescence imaging system enables visualization over a wide region of interest, and provides intuitive information on perfusion intraoperatively. Surgeons can choose the best anastomotic site of the gastric tube based on fluorescence images in real time during surgery. This technology provides better surgical outcomes when used with an optimal injection dose and timing of indocyanine green.

Thoracoscopic retrosternal gastric conduit resection in the supine position for gastric tube cancer

INTRODUCTION

Recent advances in the treatment for esophageal cancer have improved the prognosis after esophagectomy, but they have led to an increased incidence of gastric tube cancer. In most patients who underwent retrosternal reconstruction, median sternotomy is performed; it is associated with a risk of postoperative bleeding and osteomyelitis, and pain often negatively affects respiration. Here, we report the first case of thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S).

MATERIALS AND SURGICAL TECHNIQUE

A 75-year-old male patient was placed in the supine position. Four ports were placed in the left chest wall. The gastric tube was separated from the epicardium, sternum, and left brachiocephalic vein. Because of adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. The dorsal side of the gastric tube was dissected before the ventral side, enabling the gastric tube to be suspended from the back of the sternum and, thus, making it easier to expose the surgical field. Next, pedicled jejunal reconstruction via the presternal route was performed. There were no postoperative complications. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection.

DISCUSSION

TRGR-S does not require sternotomy, reducing the risk of postoperative bleeding and osteomyelitis. In the presence of adhesions, TRGR-S is safe and provides a good surgical view. It is also reliable procedure for resection of retrosternal gastric tube cancer, and it is ergonomic for surgeons.

Subtotal gastrectomy for gastric tube cancer using intraoperative indocyanine green fluorescence method

INTRODUCTION

Currently, the frequency of evaluating the flow of a reconstructed gastric tube using indocyanine green (ICG) fluorescence has been increasing. However, it has been difficult to decide on the operation method for patients with gastric tube cancer (GTC). We herein report a case in which ICG was effective in a patient with resection of GTC.

PRESENTATION OF CASE

An 83-year-old man underwent subtotal esophagectomy with gastric tube reconstruction via the retrosternal route for esophageal cancer and right hemicolectomy for ascending colon cancer 16 years earlier. Postoperatively, the proximal part of the gastric tube had poor blood flow. Therefore, the patient underwent proximal-side resection of the gastric tube. Thereafter, free jejunal graft reconstruction was performed. The patient had not developed recurrence at that point. Recently, the patient visited the hospital complaining of nausea and chest discomfort. Upper gastrointestinal endoscopy revealed a type 0-IIa + IIc lesion located around the pylorus. A biopsy showed adenocarcinoma. Based on these findings, the patient was diagnosed with gastric tube cancer (cT1bN0M0StageI). The invasion depth of the cancer was predicted to be widespread submucosal invasion. Therefore, the patient underwent surgery. Intraoperatively, we evaluated the flow of the gastric tube after clamping the right gastroepiploic artery using ICG fluorescence. As a result, the flow of the gastric tube was deemed insufficient. Consequently, subtotal gastrectomy was performed with preservation of the right gastroepiploic artery via Roux-en-Y reconstruction.

DISCUSSION

ICG fluorescence is useful for evaluating the flow of the gastric tube helping to decide the operating method.

CONCLUSION

We herein report a case of subtotal gastrectomy for GTC using intraoperative ICG fluorescence.

Successful preservation of the proximal stomach tube by evaluating blood flow using indocyanine green for gastric tube cancer: a case report

BACKGROUND

There have been two reports on preserving the proximal gastric tube by using intraoperative indocyanine green (ICG)-based photodynamic detection to evaluate blood flow through the anastomosis for gastric tube cancer after esophagectomy. However, in those cases, the period since the first operation was > 3 years 11 months, and there have been no reports of cases with < 1-year periods after the first operation.

CASE PRESENTATION

A 59-year-old man underwent video-assisted thoracic subtotal esophagectomy and gastric tube reconstruction after two courses of preoperative chemotherapy for middle thoracic esophageal cancer. After half a year, follow-up upper gastrointestinal endoscopy showed a submucosal tumor in the posterior wall of the pre-pyloric region. We performed a biopsy, and the results led to a diagnosis of gastric cancer (moderately differentiated adenocarcinoma: tub2). Clinically, the patient was described as having stage IB (cT2N0M0) gastric cancer of the reconstructed gastric tube. To avoid total gastrectomy, we tried to evaluate the blood flow of the proximal part of the gastric tube by intraoperative ICG-based photodynamic detection. Intraoperative findings confirmed neo-vascularization from the remnant cervical esophagus to the upper region of the gastric tube approximately 7 cm through the esophagogastric anastomosis. Therefore, we dissected the distal part of the gastric tube approximately 4 cm from the esophagogastric anastomosis and then performed Roux-en-Y gastro-jejunostomy via the ante-sternum route. The postoperative course was stable, and the patient was discharged on the 14th postoperative day.

CONCLUSIONS

ICG-based photodynamic diagnosis was found to be simple and less invasive. Therefore, even if the postoperative period is short, this method should be considered for evaluation of blood flow prior to performing less invasive surgery.

The evaluation of the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy

OBJECTIVE

We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

METHODS

Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO₂: 0-99%) and total hemoglobin index (T-HbI: 0-1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared.

RESULTS

The mean values of rSO₂ at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO₂ gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461).

CONCLUSION

A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

Visualization and quantification of anastomotic perfusion in colorectal surgery using near-infrared fluorescence

BACKGROUND

Anastomotic leakage (AL) is one of the most troublesome complications in colorectal surgery. Recently, near-infrared fluorescence (NIRF) imaging has been used intraoperatively to detect sentinel lymph nodes and visualize the blood supply at the region of interest (ROI). The aim of this study was to evaluate the role of visualization and quantification of bowel perfusion around the anastomosis using NIRF system in predicting AL.

METHODS

A prospective study was conducted on patients who had laparoscopic surgery for colorectal cancer at our institution. Perfusion of the anastomosis was evaluated with NIRF imaging after intravenous injection of indocyanine green (ICG). The time course of fluorescence intensity was recorded by an imaging analyzer We measured the time from ICG injection to the beginning of fluorescence (T₀), maximum intensity (I_max), time to reach I_max (T_max), time to reach I_max 50% ([Formula: see text]) and slope (S) after the anastomosis.

RESULTS

Tumor locations were as follows; cecum: 2, ascending colon: 2, transverse colon: 7, descending colon: 1, sigmoid colon: 2, rectosigmoid colon: 3 and rectum: 6 (one case with synchronous cancer). All operations were performed laparoscopically. Four patients were diagnosed with or suspected to have AL (2 patients with grade B anastomotic leakage after low anterior resection, 1 patient with minor leakage in transverse colon resection and 1 patient needing re-anastomosis intraoperatively in transverse colon resection). T₀ was significantly longer in the AL group than in patients without AL (64.3 ± 27.6 and 18.2 ± 6.6 s, p = 2.2 × 10^-3).

CONCLUSIONS

Perfusion of the anastomosis could be successfully visualized and quantified using NIRF imaging with ICG. T₀ might be a useful parameter for prediction of AL.

Gastric tube cancer after esophagectomy for cancer: a systematic review

Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

Case report: Gastric tube cancer after esophagectomy-Retrograde perfusion after proximal resection of right gastroepiploic artery

INTRODUCTION

We report a case of a 57-year-old patient with gastric tube cancer after subtotal esophagectomy and retrosternal gastric pull up.

CASE PRESENTATION

The patient developed gastric cancer 4 years after undergoing treatment for esophageal squamous cell cancer; the treatments included thoracoscopic subtotal esophagectomy, gastric pull-up reconstruction via a retrosternal route in salvage setting following definitive chemoradiation. Because the gastric tube cancer was located around the pylorus, transabdominal partial resection, which is much less invasive than total resection via sternotomy, was performed. During surgery, retrograde pulsation of the proximally resected right gastroepiploic artery was observed. Owing to an ample blood supply to the oral remnant of the gastric tube, vascular reconstruction of the right gastroepiploic artery was omitted. The postoperative recovery was eventless.

DISCUSSION

The right gastroepiploic artery is considered essential for blood supply to the gastric tube. However, there was no sign of ischemia after proximal resection of this artery, which suggests the vasculature was altered after gastric tube construction.

CONCLUSION

This case shows that partial distal resection of the gastric tube can be performed safely without vascular reconstruction of the right gastroepiploic artery. Favorable long-term results after gastric tube reconstruction support the possibility of bilateral blood supply to the gastroepiploic arcade.

Less Invasive Surgery for Remnant Stomach Cancer After Esophago-proximal Gastrectomy with ICG-guided Blood Flow Evaluation: A Case Report

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICG-based evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature.

Usefulness of indocyanine green fluorescence imaging: A case of laparoscopic distal gastrectomy after distal pancreatectomy with splenectomy

Safe preservation of the remnant stomach during distal gastrectomy in patients who have undergone distal pancreatectomy is important. During distal pancreatectomy, the splenic artery that supplies arterial blood to the cardiac part of stomach is resected. Previous reports suggested that blood flow to the remnant stomach may be insufficient when supplied by only the left inferior phrenic artery. In the present case, a 79-year-old woman who underwent distal pancreatectomy with splenectomy 20 years before she was diagnosed with gastric cancer and referred to our hospital. We performed laparoscopic distal gastrectomy and Roux-en-Y reconstruction because preoperative CT scan indicated a developed left inferior phrenic artery. To evaluate the blood supply, we employed indocyanine green fluorescence and were able to safely preserve the remnant stomach. Our experience suggests that indocyanine green fluorescence is potentially useful for evaluating blood flow to the remnant stomach.

Evaluation of laparoscopic cholecystectomy using indocyanine green cholangiography including cholecystitis: A retrospective study

Intraoperative cholangiography involving the excretion of fluorescent indocyanine green (ICG) into the bile is used to determine biliary anatomy in laparoscopic cholecystectomy (LC). This study aimed to evaluate the features of intraoperative ICG cholangiography, in LC with cholecystitis, and compared the delineation of the cystic duct (CD) between ICG cholangiography and magnetic resonance cholangiopancreatography (MRCP).Participants comprised 65 patients undergoing LC using ICG cholangiography.Fifty-eight patients (89.2%) were diagnosed with gallbladder stones and 32 (49.2%) with acute cholecystitis. ICG cholangiography identified CD in 54 patients (83.1%) and did not identify CD in 11 patients (16.9%). The mean value of the fluorescence intensity in the identified CD group by ICG cholangiography was 87.6 ± 31.5 arbitrary unit and that in the not identified CD group by ICG cholangiography was 24.4 ± 10.1 arbitrary unit (P < .001). Compared with the patients in the identified CD group, those in the not identified CD group had higher incidence of acute cholecystitis (P < .001), and higher conversion rates (P = .003). A correlation between the delineation of CD by ICG cholangiography and MRCP was analyzed, and it revealed a correlation between each other (P = .002)Inflammation had harmful effects with regard to the passing of CD. If we can identify CD or common bile duct with ICG cholangiography, we may be able to perform LC with confidence, even in the presence of severe inflammation.

A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery

Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.

Usefulness of fluorescence vascular imaging for evaluating splenic perfusion

BACKGROUND

The aim of this study was to confirm whether intraoperative fluorescence vascular imaging using indocyanine green (FVI-ICG) is useful for evaluating splenic perfusion after spleen-preserving distal pancreatectomy (SPDP) performed with the Warshaw technique (SPDP-W).

METHODS

We evaluated the blood perfusion of the spleen with an intraoperative FVI-ICG system after SPDP-W. All of the patients underwent dynamic computed tomography (CT) scans at one post-operative week and one post-operative month to evaluate the post-operative blood perfusion of the spleen. Then, the post-operative perfusion status of the spleen according to CT and the intraoperative fluorescence status of the spleen were compared.

RESULTS

Five patients were enrolled in this study. None of the patients required secondary splenectomies. We detected a tendency towards a close relationship between the intraoperative fluorescence level of the spleen according to FVI-ICG performed after SPDP-W and post-operative splenic perfusion as evaluated by CT. Improved splenic perfusion was seen at one post-operative month in all cases, including a case in which poor splenic perfusion was initially detected.

CONCLUSION

We detected a close relationship between the fluorescence level of the spleen on intraoperative FVI-ICG and the post-operative perfusion status of the spleen among patients who underwent SPDP-W. Intraoperative FVI-ICG could help surgeons to safely preserve the spleen after SPDP-W.

Left Gastric Artery Reconstruction after Distal Pancreatectomy with Celiac Axis En-Bloc Resection: How We Do It

BACKGROUND/AIMS

Ischemic gastropathy remains as a persistent problem after left gastric artery (LGA) resection in distal pancreatectomy with celiac axis en-bloc resection (DP-CAR). The middle colic artery (MCA) was found to be a useful vessel for compromised collateral flow. However, intraoperative gross evaluation of gastric ischemia is technically difficult even after artery reconstruction.

METHODS

We performed LGA reconstruction by MCA-LGA bypass after LGA-resecting DP-CAR assisted by intraoperative indocyanine green fluorescence imaging (ICG) blood flow evaluation in a clinical trial (UMIN000020414). The LGA was reconstructed with the MCA microscopically by plastic surgeons with an everting interrupted suture in end-to-end anastomosis.

RESULTS

We could evaluate ICG blood flow not only in the reconstructed artery, but also simultaneously in the gastric wall through a monitor connected to a detector. We could also assess the congestive status of the gastric wall by ICG disappearance from the gastric wall.

CONCLUSION

We present LGA reconstruction by MCA-LGA bypass after LGA-resecting DP-CAR. We conducted a perioperative assessment of ischemic gastropathy to confirm the feasibility and safety of this procedure.

Usefulness of Fluorescence Vascular Imaging for Preserving the Remnant Stomach After Distal Pancreatosplenectomy: A Case Report

Due to recent developments in medical treatment, the number of patients that undergo multiple surgical procedures for secondary metachronous cancer is increasing. In cases in which patients undergo distal pancreatosplenectomy after distal gastrectomy, surgeons might have concerns about whether they are able to preserve the remnant proximal stomach because the main feeding vessels will have been divided in the previous procedure. Herein, we report a case in which a patient underwent distal pancreatosplenectomy 20 years after undergoing distal gastrectomy, and the remnant proximal stomach was successfully preserved with the help of intraoperative fluorescence vascular imaging using indocyanine green (FVI-ICG). A 65-year-old female was referred to our hospital due to upper gastric pain and was diagnosed with cancer of the pancreatic body. She had undergone distal gastrectomy 20 years earlier for early stage gastric cancer. Therefore, the blood supply to the remnant stomach left after the distal pancreatectomy procedure might have been insufficient. To determine the adequacy of the blood supply to the remnant proximal stomach after distal pancreatosplenectomy, we conducted intraoperative FVI-ICG. Because strong fluorescence was detected, we were able to safely preserve the remnant stomach. At 4 and 8 months after surgery, computed tomography showed good blood flow through the remnant stomach. FVI-ICG is useful for evaluating the blood supply to tissues, and hence, can be used to predict the blood supply of residual organs.

Resection of distal gastric tube cancer with sentinel node biopsy: a case report and review of the literature

Background

The frequency of gastric tube cancershas increased with advances in surgical techniques and improvement of survival rates in patients with esophageal cancer. However, a standard surgical treatment has not yet been established. Total resection of the gastric tube with lymphadenectomy has been considered a radical treatment, while repeat surgery with both laparotomy and thoracotomy has been associated with severe complications, including anastomotic leakage, recurrent nerve paralysis, bronchotracheal injury, and damage to other organs.

Case presentation

We present a successful case of a gastric tube cancer that was treated with surgical resection in combination with sentinel node biopsy. The tumor was diagnosed as a type 0-IIc lesion with ulceration, and was located proximal to the pyloric ring. Endoscopic submucosal dissection was not indicated because the primary lesion was submucosally invasive, and undifferentiated. By the dye-guided method, sentinel nodes were detected along the right gastroepiploic artery and vein. Intraoperative pathological examination revealed no metastasis of the sentinel nodes. Resection of the distal gastric tube was safely performed with a Roux-en-Y reconstruction, preserving the right gastroepiploic artery and vein and the perfusion of the proximal gastric tube.

Conclusion

We suggest distal resection of the gastric tube with sentinel node biopsy as a novel surgical method for a cT1N0 gastric tube cancer located in the abdomen.

Hemodynamics of the reconstructed gastric tube during esophagectomy: assessment of outcomes with indocyanine green fluorescence

BACKGROUND

Construction of a gastric tube that is well perfused with blood during esophagectomy is the most important factor in avoiding anastomotic leakage. We clarified the hemodynamics of the reconstructed gastric tube with indocyanine green (ICG) fluorescence.

METHODS

In 20 patients undergoing gastric tube reconstruction during esophagectomy, we evaluated blood flow in the gastric tube with ICG fluorescence imaging. We divided the patients into two groups according to the quality of blood flow to the gastric tube-"good" (n = 9) and "sparse or absent" (n = 11)-based on visual assessment of the anastomosis of the right and left gastroepiploic vessels. We measured the time from initial enhancement of the root of the right gastroepiploic artery until enhancement of the most cranial branch of the left gastroepiploic artery and tip of the gastric tube.

RESULTS

The gastric tube was divisible into three zones according to the dominant arteries present in the greater curvature under ICG fluorescence. The left gastroepiploic artery was enhanced in a direction opposite that of physiological blood flow in all cases. The median period from initial enhancement of the root of the right gastroepiploic artery to the most cranial branch of the left gastroepiploic artery until perfusion up to the tip of the gastric tube did not differ significantly between the "good" and the "sparse or absent" groups (P = 0.24, 0.68) CONCLUSIONS: It is essential to preserve the whole vessel arcade of the greater curvature to achieve good blood perfusion in the gastric tube. The ICG fluorescence method has potential usefulness for evaluation of blood flow in the gastric tube.

The effect of narrowed gastric conduits on anastomotic leakage following minimally invasive oesophagectomy

OBJECTIVES

Anastomotic leakage remains a major complication following minimally invasive oesophagectomy (MIO). In this study, our objective was to determine whether a narrower gastric conduit would lead to lower incidence of anastomotic leakage following MIO.

METHODS

In this retrospective study, patients with oesophageal cancer undergoing MIO were assigned to receive 5-cm-wide gastric conduits (from May 2011 to February 2012, Group W) and then 3-cm-wide gastric conduits (from March 2012 to December 2012, Group N) for gastro-oesophageal anastomosis. The length of the gastric conduit and the anastomotic details were recorded during surgery. Perfusion status of the conduit was analysed before and after anastomosis using a laser Doppler perfusion monitor. Following surgery, the incidence of anastomotic leakage in the two groups was statistically compared to identify differences between the two methods of gastric formation.

RESULTS

There were 126 patients in Group N and 133 patients in Group W. Patient demographics and surgical observations were comparable between the two groups. In Group N, the length of gastric conduit was significantly greater than in Group W (39.1 ± 2.7 vs 35.6 ± 4.4 cm, P = 0.0021). Lower reduction of perfusion units was recorded in Group N after gastro-oesophageal anastomosis (45.7 vs 28.1%, P = 0.004). Postoperatively, a total of 34 cases (13.13%) of anastomotic leakage was observed, and the incidence of anastomotic leakage was significantly lower in Group N than in Group W (8.7 vs 17.3%, P = 0.041).

CONCLUSIONS

Narrow gastric tubes were longer and less interfered in perfusion, which contributed to lower incidence of anastomotic leakage following minimally invasive oesophagectomy. Further study of the long-term effects of such treatment is required to confirm the advantages of this technique.