Pancreaticoduodenectomy after postoperative gastric tube reconstruction for esophageal cancer with median arcuate ligament syndrome: a case report.

BACKGROUND: Pancreaticoduodenectomy (PD) is considered a challenging surgery for resecting the gastroduodenal artery (GDA), right gastric artery (RGA), and lymph node tumors. In cases of pancreatic head cancer surgery, vascular anastomosis or right gastroepiploic artery (RGEA)/GDA preservation is necessary after postoperative gastric tube reconstruction for esophageal cancer. Therefore, we report for the first time an extremely rare case of PD in a patient with pancreatic head cancer and median arcuate ligament syndrome (MALS) after gastric tube reconstruction following esophageal cancer surgery, in which the entire pancreatic head arcade was preserved. CASE PRESENTATION: The patient was a 76-year-old man who had undergone esophageal cancer surgery after sternal gastric tube reconstruction 7 years ago. He was referred to our hospital because of the suspicion of intraductal papillary mucinous carcinoma (IPMC) owing to an enlarged cystic lesion and a substantial component in the uncinate process of the pancreas. Preoperative three-dimensional computed (3D-CT) tomography angiography showed celiac axis stenosis and pancreatic head arcade dilation. The diagnosis was IPMC without evidence of invasion; therefore, gastric tube blood flow was maintained by preserving the GDA and RGEA. Due to MALS, the GDA blood flow was supplied through the pancreatic head arcade, necessitating its preservation. The GDA-RGEA, right gastroepiploic vein, and anterior superior pancreaticoduodenal artery were taped over the entire pancreatic head for preservation. The inferior pancreaticoduodenal artery (IPDA) was also taped on the dorsal pancreas and the posterior or anterior IPDA, which further bifurcates were taped to preserve them. Subsequently, PD was performed. CONCLUSION: We report a case of PD after gastric tube reconstruction for esophageal cancer with MALS, in which the pancreatic head arcade vessels were successfully preserved using 3D-CT to confirm the operation of the vessels.

99mTc-Sn-colloid SPECT/CT in thoracic splenosis after esophageal cancer surgery.

Splenosis occurs as a result of autotransplantation of splenic tissue following splenic injury or splenectomy. A 56-year-old man with esophageal cancer underwent thoracoscopic-assisted subtotal esophagectomy accompanied by three-field lymph node dissection, and retrosternal gastric tube reconstruction. The spleen was injured during the surgery and was removed. A retrosternal nodule of 12 mm in diameter was detected near the reconstructed gastric tube on computed tomography (CT) performed 3 years and 6 months postoperatively. Retrospectively, the nodule was observed in the same area on early postoperative CT and gradually increased in size. No accessory spleen was identified on the preoperative CT. Splenosis was suspected, and 99mTc-Sn-colloid single photon emission computed tomography (SPECT)/CT was performed. It revealed intense uptake in the retrosternal nodule, consistent with the diagnosis of thoracic splenosis. Subsequently, the patient has been under observation without treatment. 99mTc-labeled colloid SPECT/CT allowed confident diagnosis of thoracic splenosis following esophageal cancer surgery. This examination is considered valuable for the evaluation of ectopic splenic tissue.

Acute type A aortic dissection surgery in retrosternal gastric tube reconstruction patient.

BACKGROUND: Retrosternal gastric tube reconstruction is a common surgical technique for managing esophageal cancer, but it complicates acute type A aortic dissection repair and raises concerns about gastric tube damage. CASE PRESENTATION: A 73-year-old female, who underwent esophagectomy with retrosternal gastric tube reconstruction 6 months ago for esophageal cancer, presented with severe chest pain. Acute type A aortic dissection was confirmed by contrast-enhanced computed tomography, and emergency hemiarch replacement through a median sternotomy was performed, preserving the gastric tube without injury. The patient recovered well and was discharged after 3 weeks, showing no gastrointestinal symptoms or signs of mediastinitis.

Combined endoscopic stenting and laparoscopic stent fixation for benign gastric tube stricture after esophagectomy: a case report.

BACKGROUND: There are several options for the treatment of gastrointestinal stricture, including endoscopic stent placement and bypass surgery. However, a benign stricture is difficult to manage in a reconstructed gastric tube in the thoracic cavity owing to the technical difficulty of bypass surgery, and the possibility of stent migration. CASE PRESENTATION: A 78-year-old woman was admitted to our hospital for treatment for her inability to eat. She had undergone video-assisted subtotal esophagectomy with retromediastinal gastric tube reconstruction 7 years earlier. At the current admission, there was a severely dilated gastric tube in the thoracic cavity with a soft stricture immediately anterior to the spine. Conservative therapy was ineffective; therefore, endoscopic stenting was performed. However, the stent migrated to the upper side of the stricture because the stricture was mild, and the stent was not fixed in the gastric tube. Next, endoscopic stent placement followed by laparoscopic stent fixation was performed. The stent was patent and worked well, and the patient's body weight increased. However, the stent collapsed 2 years later, with recurrence of symptoms. Stent-in-stent placement with an over-the-scope clip was performed, and the second stent was also patent and worked well. CONCLUSIONS: Laparoscopic stent fixation with endoscopic stent placement could be an effective option for patients with a benign stricture in the reconstructed gastric tube.

Surgical outcomes of laparoscopic proximal gastrectomy for upper-third gastric cancer: esophagogastrostomy, gastric tube reconstruction, and double-tract reconstruction.

BACKGROUND: There is no consensus on the optimal reconstruction technique after proximal gastrectomy. The purpose of this study was to retrospectively compare the surgical outcomes among esophagogastrostomy (EG) anastomosis, gastric tube (GT) reconstruction and double-tract (DT) reconstruction in patients who underwent laparoscopic proximal gastrectomy (LPG) to clarify the superior reconstruction method. METHODS: This study enrolled 164 patients who underwent LPG at the Northern Jiangsu People's Hospital in Jiangsu between January 2017 to January 2022 (EG: 51 patients; GT: 77 patients; DT: 36 patients). We compared the clinical and pathological characteristics, surgical features, postoperative complications, nutritional status, and quality of life (QOL) among the above three groups. RESULTS: Mean operative time was longer with the DT group than the remaining two groups (p = 0.001). With regard to postoperative complications, considerable differences in the postoperative reflux symptoms (p = 0.042) and reflux esophagitis (p = 0.040) among the three groups were found. For the nutritional status, total protein, hemoglobin and albumin reduction rates in the GT group were significantly higher than the other two groups at 12 months postoperatively. In the PGSAS-45, three assessment items were better in the DT group significantly compared with the esophageal reflux subscale (p = 0.047, Cohen's d = 0.44), dissatisfaction at the meal (p = 0.009, Cohen's d = 0.58), and dissatisfaction for daily life subscale (p = 0.012, Cohen's d = 0.56). CONCLUSIONS: DT after LPG is a valuable reconstruction technique with satisfactory surgical outcomes, especially regarding reduced reflux symptoms, improving the postoperative nutritional status and QOL.

Experience with transesophageal echocardiography for mitral valve plasty in the remote stage after esophagectomy with gastric tube reconstruction via the retrosternal route.

A 69-year-old male patient with mitral valve prolapse was scheduled for mitral valve plasty. Sixteen years earlier, he had undergone right open thoracotomy for esophageal cancer with subtotal esophagectomy, cervicothoraco-abdominal three-region dissection, posterior mediastinal tube reconstruction, and cervical anastomosis. Postoperatively, the patient had a treatment- and recurrence-free course, and an upper gastrointestinal endoscopy performed 2 years prior revealed no abnormality. We scheduled a transesophageal echocardiography for mitral valve surgery. We attempted to insert the probe but felt resistance at the height of the mid-thoracic region, and the image quality was poor, so we abandoned the intraoperative diagnosis. The surgery was performed as planned, and when the probe was manipulated again at the time of cardiopulmonary withdrawal, the mitral valve could be observed. The mitral valve was judged to be sufficiently repaired, and the surgery was terminated. There were no complications associated with transesophageal echocardiography.

Endoscopic vacuum therapy significantly improves clinical outcomes of anastomotic leakages after 2-stage, 3-stage, and transhiatal esophagectomies.

BACKGROUND: Anastomotic leakages after esophagectomies continue to constitute significant morbidity and mortality. Intrathoracic anastomoses pose a high risk for mediastinitis, sepsis, and death, if a leak is not addressed timely and appropriately. However, there are no standardized treatment recommendations or algorithms as for how to treat these leakages. METHODS: The study included all patients at the University Hospital Regensburg, who developed an anastomotic leakage after esophagectomy with gastric pull-up reconstruction from 2007 to 2022. Patients receiving conventional treatment options for an anastomotic leakage (stents, drainage tubes, clips, etc.) were compared to patients receiving endoscopic vacuum-assisted closure (eVAC) therapy as their mainstay of treatment. Treatment failure was defined as cervical esophagostomy formation or death. RESULTS: In total, 37 patients developed an anastomotic leakage after esophagectomy with a gastric pull-up reconstruction. Twenty patients were included into the non-eVAC cohort, whereas 17 patients were treated with eVAC. Treatment failure was observed in 50% of patients (n = 10) in the non-eVAC cohort and in 6% of patients (n = 1) in the eVAC cohort (p < 0.05). The 90-day mortality in the non-eVAC cohort was 15% (n = 3) compared to 6% (n = 1) in the eVAC cohort. Cervical esophagostomy formation was required in 40% of cases (n = 8) in the non-eVAC cohort, whereas no patient in the eVAC cohort underwent cervical esophagostomy formation. CONCLUSION: eVAC therapy for leaking esophagogastric anastomoses appears to be superior to other treatment strategies as it significantly reduces morbidity and mortality. Therefore, we suggest eVAC as an essential component in the treatment algorithm for anastomotic leakages following esophagectomies, especially in patients with intrathoracic anastomoses.

Right-parasternal approach for aortic valve replacement and ascending aortic repair after ante-thoracic route gastric tube reconstruction.

Due to the limitations of surgical incisions and approaches brought on by the presence of gastric tube (GT), open heart surgery following ante-thoracic route GT reconstruction remains challenging. A-73-year-old man, who had a history of esophageal resection and ante-thoracic route GT reconstruction required aortic valve replacement (AVR) concomitant with ascending aortic repair (AAR) for aortic stenosis and dilated ascending aorta. We performed open heart surgery via a right-parasternal approach to avoid injury to the GT and nutrient arteries. This approach provided a good operative field, similar to median sternotomy. To our knowledge, this is the first case of AVR concomitant with AAR after ante-thoracic route GT reconstruction via a right-parasternal approach. We consider that the right-parasternal approach is reasonable for patients with ante-thoracic route GT reconstruction.

Left Hemihepatectomy for Hepatocellular Carcinoma Following Esophagectomy with Retrosternal Gastric Tube Reconstruction for Esophageal Cancer.

Approximately 4% of patients with esophageal cancer develop a second primary malignancy in the upper gastrointestinal trunk. However, hepatectomy following esophagectomy for esophageal cancer has rarely been reported. We report the case of a 70-year-old man who underwent an esophagectomy for esophageal cancer with retrosternal gastric tube reconstruction. Nine years later, he developed hepatocellular carcinoma with tumor thrombus involving the left portal vein, and was successfully treated with left hemihepatectomy. Special attention should be paid to avoiding incidental injury of the gastric tube as well as the right gastroepiploic artery during the hepatectomy.

Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation.

INTRODUCTION: Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. METHODS: Between 2015 and 2018, patients with delayed gastric emptying 8-10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. RESULTS: Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9-15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. CONCLUSION: Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.

Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment.

Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.

Columnar epithelium morphology after esophagectomy: clinical insight into the development of Barrett's esophagus.

BACKGROUND: The presence of Barrett's mucosa in the esophageal remnant is a result of post-esophagectomy anastomotic site exposure to gastric acid and is regarded as a human model of Barrett's esophagus onset. Here, we attempted to clarify the relationship between duodenogastric reflux and formation of columnar epithelium by following the changes over time after esophagectomy. METHODS: A total of 96 patients underwent esophagectomy due to superficial cancer from April 2000 to March 2018 were included in this study. Cases were divided into two groups according to the reconstruction technique after esophagectomy as either the gastric pull-up (Ga) group and ileocolonic interposition (Ic) group. Previously obtained endoscopic pictures of the cases were reviewed retrospectively and chronologically. RESULTS: There were 24 cases of columnar epithelium in the Ga group (42%) and 1 in the Ic group (2.6%) (P < 0.01) with 32 reflux cases (56%) in the Ga group and 1 (2.6%) in the Ic group (P < 0.01). Reflux precedes the development of columnar epithelium in both the Ga- and Ic groups. Multivariate analysis revealed surgical technique (odds ratio 10.6, 95% CI 1.2-97.5, P = 0.037) and reflux (odds ratio 4.5, 95% CI 1.3-15.6, P = 0.0017) as risk factors. CONCLUSIONS: The development of columnar epithelium was preceded by reflux comprising principally gastric acid and was strongly associated with a strong inflammatory state.

Pancreaticoduodenectomy following surgery for esophageal cancer with gastric tube reconstruction: a case report and literature review.

BACKGROUND: Synchronous and asynchronous multiple cancers have become more pervasive in recent years despite advances in medical technologies. However, there have been only six cases (including the present case) that underwent pancreaticoduodenectomy (PD) for pancreas head cancer following surgery for esophageal cancer. PD for treating pancreas head cancer is extremely challenging; thus, the confirmation of vessel variation and selection of surgical procedures are vital. CASE PRESENTATION: The patient was a 78-year-old Japanese male who was synchronously diagnosed with esophageal and cecal cancer 7 years previously at our hospital. He was admitted with densely stained and jaundiced urine and presented no remarkable family medical history. Following various examinations, surgery was performed due to the diagnosis of distal cholangiocarcinoma (pancreatic head cancer). Since the tumor was located far from the gastroduodenal artery (GDA) and no significant lymph node metastases could be found, subtotal stomach-preserving PD was performed instead of the resection of GDA with the right gastroepiploic artery (RGEA) for gastric tube blood flow preservation. The common hepatic artery (CHA) and GDA were confirmed, and RGEA diverged from GDA was identified. Subsequently, their respective tapings were preserved. The right gastric artery (RGA) was identified, taped, and preserved considering the gastric tube blood flow. The inflow area of the right gastroepiploic vein (RGEV) through gastric colic vein trunk in the superior mesenteric vein was exposed and preserved as the outflow of gastric tube blood flow. PD was completed without any complications on the shade of the gastric tube. CONCLUSIONS: This case report describes successfully preserved gastric blood flow without the resection of GDA, RGEA, RGEV, or RGA. To preserve the gastric tube, GDA inflow, RGEA, RGA, and RGEV outflow should be preserved if possible. When performing PD after tube reconstruction, it is essential to confirm the relative positions of the blood vessel, blood flow, and tumor through three-dimensional computed tomography angiography before surgery and to consider the balance between the invasiveness and optimal curability of the surgery.

Randomized controlled trial on efficacy of oligomeric formula (HINE E-GEL®) versus polymeric formula (MEIN®) enteral nutrition after esophagectomy for esophageal cancer with gastric tube reconstruction.

The efficacy of early enteral nutrition after esophageal cancer surgery has been reported. However, the choice of formula and management of diarrhea are important to achieve the goal of enhanced recovery after surgery. The aim of this study is to assess the frequency of diarrhea/completion rate of enteral nutrition regimen as primary endpoints and the postoperative nutritional status/body composition analysis/operative morbidity as secondary endpoints was compared between the two nutrition groups. Among the 122 patients who underwent esophagectomy for esophageal cancer between December 2015 and September 2017, 67 patients who met the eligibility criteria were randomly assigned to receive enteral nutrition with either HINE E-GEL® (HINE group; n = 33) or MEIN® (MEIN group; n = 34). The incidence of diarrhea was significantly lower in the HINE group (18.2 % vs. 64.7 %, P < 0.001). The score of Bristol scale of POD 6/7 was significantly lower in the HINE group (P = 0.019/P = 0.006, respectively). The completion rate of enteral nutrition regimen was significantly higher in the HINE group (97.4 % vs. 86.6 %, P = 0.002). The Controlling Nutritional Status scores and total protein levels at 6 months after surgery were significantly better in the HINE group (P = 0.030 and P = 0.023, respectively), indicating improved tendency in nutritional status in the HINE group. However, there were no significant differences in Prognostic Nutritional Index values, blood test results, rapid turnover proteins, body mass index, or body composition between the two groups. HINE E-GEL compared with MEIN may reduce the frequency of diarrhea, enabling patients to adhere to the scheduled enteral nutrition plan. Also, maintenance of nutritional status with HINE E-GEL was comparable or potentially better in some nutrition components to that with MEIN, indicating that HINE E-GEL can be an option for enteral nutrition following esophageal surgery to achieve the goal of successful completion of scheduled enteral nutrition and smooth transition to the normal diet.

The evolution of surgical approach for esophageal cancer.

Esophageal surgery for esophageal cancer has been performed for over a century now. Minimally invasive esophagectomy (MIE) was first described in 1992, and it is now a standard approach in many countries. However, MIE is technically difficult and requires a long learning curve. It takes >100 cases to train for MIE with gastric tube reconstruction with an intrathoracic anastomosis. A possible option to overcome several challenges of MIE might be the use of a robotic system. A robot-assisted MIE was first described in 2005, and long-term results have shown its feasibility and safety. Over the years, different approaches for esophagectomy have been established. Our review discusses these developments and recent literature on open, minimally invasive and robotic esophageal surgery.

A Case of Stanford Type A Acute Aortic Dissection after Surgery for Esophageal Cancer / 日本心臓血管外科学会雑誌

A 76-year-old man with a history of total esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer was transferred to our hospital because of consciousness disorder. It became an emergency operation on diagnosis of Stanford type A acute aortic dissection on enhanced CT. Because CT showed the retrosternal gastric tube ran along the right side of the body of the sternum through the back side of the manubrium, we opted for skin and the suprasternal incision on the left side from center. We could perform total aortic arch replacement without the damage of the gastric tube except that the right side of the operative view was slightly poor. We did not recognize digestive organ symptoms such as postoperative passage disorders nor mediastinitis. The patient was discharged from our hospital on postoperative day 24.

Laparoscopic Proximal Gastrectomy With Gastric Tube Reconstruction.

BACKGROUND AND OBJECTIVES: There is no standardized method of reconstruction in laparoscopic proximal gastrectomy (LPG). We present a novel technique of reconstruction with a long, narrow gastric tube in LPG for early gastric cancer (EGC). METHODS: During the laparoscopic procedure, the upper part of the stomach is fully mobilized with perigastric and suprapancreatic lymphadenectomy, and then the abdominal esophagus is transected. After a minilaparotomy is created, the entire stomach is pulled outside. A long, narrow gastric tube (20 cm long, 3 cm wide) is created with a linear stapler. The proximal part of the gastric tube is formed into a cobra head shape for esophagogastric tube anastomosis, which is then performed with a 45-mm linear stapler under laparoscopic view. The end of the esophagus is fixed on the gastric tube to prevent postoperative esophageal reflux. RESULTS: Thirteen patients with early proximal gastric cancer underwent the procedure. The mean operative time was 283 min, and median blood loss was 63 ml. There were no conversions to open surgery, and no intraoperative complications. CONCLUSION: This new technique of reconstruction after LPG is simple and feasible. The procedure has the potential of becoming a standard reconstruction technique after LPG for proximal EGC.

Is gastric tube reconstruction the optimal surgical procedure for Siewert type II esophagogastric junction carcinoma?

BACKGROUND/AIM: To evaluate the potential risk of gastric tube reconstruction for Siewert type II esophagogastric junction carcinoma. PATIENTS AND METHODS: We retrospectively analyzed clinicopathological and survival data of 41 patients who had undergone total gastrectomy for Siewert type II carcinoma, focusing on lymph node metastasis around the middle to lower greater curvature or parapyloric area. RESULTS: Histological examination showed involvement of at least one lymph node in six patients (14%). Multivariate Cox proportional hazard regression analysis of seven clinicopathological variables showed that lymph node metastasis around the middle to lower greater curvature, or parapyloric area was the only significant independent unfavorable factor (odds ratio=6.62; 95% confidence interval=1.27-41.1; p=0.03) for survival. We identified no significant predictors of lymph node metastasis in analyzed patients. CONCLUSION: From an oncological point of view, we do not recommend routine gastric tube reconstruction for Siewert type II carcinoma.

A Case of Acute Stanford Type A Aortic Dissection after Retrosternal Gastric Tube Reconstruction for Esophageal Cancer / 日本心臓血管外科学会雑誌

An 80-year-old man presented with a history of retrosternal gastric tube reconstruction for esophageal cancer. He experienced sudden chest pain, and temporarily lost consciousness, before being transferred to our hospital. Contrast-enhanced computed tomography revealed acute Stanford type A aortic dissection and a retrosternal gastric tube. We performed emergency operation using a median sternotomy approach. Before median sternotomy, we detected the gastric tube in the subxiphoid and suprasternal spaces. The anterior and right sides of the gastric tube were dissected bluntly from the posterior surface of the sternum and median sternotomy was performed. The gastric tube was mobilized to the left side and we were able to obtain the usual operative view for ascending aorta graft replacement. Intraoperatively, the gastric tube remained intact and uninjured. The patient was transferred to another hospital for rehabilitation on postoperative day 34.