Successful distal gastrectomy after distal pancreatectomy combined with splenectomy by assuring the blood flow to the remnant stomach from the left inferior phrenic artery.

BACKGROUND/AIMS: The current literature would suggest that patients with gastric cancer who have a previous history of ligation of the splenic artery undergo total gastrectomy. However, an analysis of the risk factors for postoperative complications in elderly patients showed a higher rate of morbidities for total gastrectomy compared to subtotal gastrectomy. Case REPORT: We herein report a rare case of successful distal gastrectomy in a 78-year-old female diagnosed with gastric cancer with a previous history of distal pancreatectomy combined with splenectomy, because an adequate blood flow was provided by the fundic branches from the left inferior phrenic artery. Preoperative computed tomography demonstrated a ligated splenic artery and left gastric artery with developed fundic branches from the left inferior phrenic artery. The intraoperative findings showed a sufficient blood flow to the proximal stomach after ligation of all main gastric arteries, thus suggesting that the gastric remnant could be supplied by the fundic branches from the LIPA. The patient's postoperative course was uneventful. CONCLUSION: This case suggests that a distal gastrectomy is a possible treatment modality even after distal pancreatectomy combined with splenectomy.

Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy.

BACKGROUND: Esophagectomy is a high-risk procedure, with significant morbidity resulting from gastric conduit failure. Early recognition and management of these complications is essential. This study aimed to investigate the clinical value of routine investigations after minimally invasive esophagectomy (MIO) and to propose a classification system for gastric conduit failure. METHODS: For esophagogastric resection, MIO is the procedure of choice in the authors' unit. Standard postoperative care similar to that for open esophagectomy is undertaken on a specialist ward. Routine investigations include daily assessment of C-reactive protein (CRP), white cell count (WCC), and a contrast swallow on postoperative day (POD) 5. The authors performed a retrospective analysis to assess the utility of these tests. RESULTS: Of a prospective cohort of 50 patients from April 2004 to July 2006, 26 (52%) had an uneventful recovery (U), 24 (48%) experienced complications (C) of varying nature and severity, and 1 died (2%). All the patients demonstrated a transient abnormal rise in CRP until POD 3. In group U, the levels then fell, but in group C, they remained elevated (POD 5: U = 96, C = 180; p < 0.01). This discrepancy trend was further exaggerated in the nine patients with gastric conduit failure (POD 5: GC = 254; p < 0.01), whereas contrast swallow failed to identify this complication in six patients. Simple anastomotic leaks (type 1, n = 4) were managed conservatively. Patients with conduit tip necrosis (type 2, n = 3) and complete conduit ischemia (type 2, n = 2) were managed by repeat thoracotomy and either refashioning of the conduit or take-down and cervical esophagostomy. None of the patients with conduit failure died. CONCLUSION: Postoperative CRP monitoring is a highly effective, simple method for the early recognition of gastric conduit failure. This new system of classification provides a successful guide to conservative management or revisional surgery.

Gastric remnant infarction following laparoscopy-assisted distal gastrectomy: CT diagnosis in two cases.

We report two cases of gastric remnant infarction following laparoscopy-assisted distal gastrectomy for the treatment of early gastric cancer. In both cases, the infarction was diagnosed with contrast-enhanced computer tomography.

[Impact of isovolumic hemodilution on the local hemodynamics of the resected stomach in patients with ulcer disease].

The influence of isovolumic hemodilution on the local hemodynamics of the resected stomach in patients with a complicated course of duodenal ulcer was studied. In the course of the analysis of parameters of the local blood flow of the intact and resected stomach, the best indices were received in patients with preoperative isovolumic hemodilution. Preoperative isovolumic hemodilution in patients with a complicated course of duodenal ulcer after the stomach resection reduces the risk of early postoperative complications.

[Influence of blood supply of the esophageal and gastric stumps on anastomotic healing after esophagogastrostomy in rabbits].

OBJECTIVE: To study how blood supply of the esophageal and gastric stumps influences the anastomotic healing after esophagogastrostomy in rabbits. METHODS: Twenty-seven New Zealand rabbits were randomly divided into 3 groups to receive esophagogastrostomy, followed by different procedures. Except for those in group I, all the rabbits were subjected to procedures of reducing the blood supply either of the esophageal or the gastric stump (group II and group III, respectively), followed by single-layer esophagogastric anastomoses using interrupted 5-0 polypropylene sutures. Ten days after operation, all the rats were killed and the anastomotic sites excised for measurement of the inner diameter, tensile strength, and hydroxyproline concentration. RESULTS: Healing of the esophagograstric anastomosis was obtained in all the rabbits but one with anastomotic leakage in group I and one with perforation of the gastric fundus in group III. The anastomotic inner diameters were similar in all the three groups, whereas the tensile strength and hydroxyproline concentration at the anastomoses decreased in group III in comparison with the other two groups (P<0.05) that had similar measurements (P>0.05). CONCLUSIONS: Extended length of the free esophageal stump does not significantly affect anastomotic healing as decrease of blood supply in the gastric stump.

[Ischaemic stump necrosis after subtotal gastric resection - a rare complication]. / Eine seltene Komplikation - ischämische Stumpfnekrose - nach subtotaler Magenresektion.

The development of gastric stump necrosis after subtotal gastrectomy with Roux-en-Y loop reconstruction and splenectomy in a patient with gastric cancer is described. The patient's life could be saved by re-operations on the 12th and 50th postoperative day. Due to the patient's poor general condition and local peritonitis the gastric stump was removed and a catheter-jejunostomy was prepared by using the Roux-en-Y loop. The aboral end of the oesophagus was closed. To relieve the oesophageal stump a cervical mucoso-oesophagostoma was carried out. As the patient's general condition improved the reconstruction of the alimentary tract was performed by preparing a new Roux-en-Y loop oesophago-jejunostomy and by closing the mucoso-oesophagostoma.9 years after the operation the patient died of pulmonary metastases. The reasons for the delayed re-operation and the advantages of the cervical mucoso-oesophagostoma are explained.

[Vascularization of the gastric stump tubule in esophagogastroplasty (EGP)]. / La vascolarizzazione del tubulo gastrico nell'esofagogastroplastica (EGP).

The authors present the results of the vascular supply of tubulized gastric stump in patients who had sub-total oesophagectomy and cervical oesophago-gastroplasty (OGP) for oesophageal carcinoma, evaluating the importance of altered tubulized gastric stump's vascular supply on oesophago-gastric anastomosis efficiency. From April 1989 up today 51 patients who had OGP entered this study. Among these 2 had intestinal reconstruction by whole stomach and 49 by tubulized gastric stump. These 49 patients had celiac and upper mesenteric arterial angiography 30 days after surgery. As regards vascular patency angiography allowed us to divide the tubulized gastric stump into three parts; giving useful information above all on the distal part of the stump, considered "at risk" as concerning vascular supply. The authors thus demonstrate that the anastomosis high rate dehiscence is preferably due to the oesophageal stump vascular supply (strongly affected by cervical dissection) rather than to the poor vascular supply of the distal third of the transposed tubulized gastric stump.

[Study on feeding arteries and lymphatic drainage of remnant stomach cancer using angiography and fine activated carbon particles].

Preoperative angiography was performed on 29 patients with remnant stomach cancer. The tumor vessels of the remnant stomach cancer were angiographically identified in 25 patients whose left gastric artery had been left intact (11 cases) or removed (14 cases) in their last operation. Lymph node metastases were examined in relation to the tumor vessels in 96 cases of initial cancer in the upper third of the stomach. Fine activated carbon particles (CH40) were endoscopically injected into the submucosal layer of the stomach in 13 patients with remnant stomach cancer two days before their operation. Blackening of the lymph nodes by CH40 was observed and the effect of removing the left gastric artery on lymphatic drainage was analyzed. Findings from these studies are summarized as follows: In cases of remnant stomach cancer where the left gastric artery was left intact, the tumor vessels most often included the left gastric artery and lymphatic drainage proceeded mainly through the left gastric artery and branches of the splenic artery (the posterior gastric artery, the left gastroepiploic artery, and the short gastric artery) to the para-aortic lymph nodes. In cases where the left gastric artery was removed, the tumor vessels were made up of branches of the splenic artery and lymphatic drainage was mainly through branches of the splenic artery to the para-aortic lymph nodes.

Regional blood flow and reflux gastritis in the resected stomach.

Laser Doppler flowmetry (LDF) was used for endoscopic measurement of regional blood flow in 20 patients who had undergone previous gastric resection for peptic ulcer. Twenty-five patients with intact stomach and normal endoscopic findings were used as controls. In resected patients, the degree of enterogastric reflux gastritis was assessed by subjective grading and by morphological examination of biopsies from the region of the gastroenterostomy. In patients with an intact stomach, the average blood flow was significantly higher in the body of the stomach compared to the antrum (p < 0.001), without any significant differences between the greater and lesser curvature. In resected patients, the average blood flow in the gastric body remnant was markedly higher than in the region of the gastroenterostomy, but also significantly higher than the corresponding area of the gastric body in patients with an intact stomach (p < 0.01). The degree of gastritis in the region of the stoma of resected patients was often overestimated on subjective endoscopic assessments compared to morphological biopsy examinations. The degree of histological gastritis was not significantly correlated to blood flow levels of the gastroenterostomy. It is concluded that low gastric wall perfusion, impeding mucosal defense, does not seem to be a major factor in the development of enterogastric reflux gastritis in the resected stomach.