Simultaneous Vascular Reconstruction and Cervical Anastomosis in McKeown Esophagectomy

Venous Supercharging Relieves Venous Congestion and Salvages Gastric Conduit Post-esophagectomy

The purpose of this study was to evaluate the effectiveness of incorporating additional venous anastomoses (venous super charging) in improving gastric conduit congestion and preventing complications such as conduit loss and anastomotic leakage following esophagectomy. We included two consecutive patients, one undergoing esophagectomy and the other undergoing laryngo-pharyngo-esophagectomy. Additional venous anastomoses were performed to alleviate venous congestion at the oral end of the gastric conduit. The perfusion assessment of the anastomosis was evaluated using indocyanine green fluorescence angiography (ICG FA) by Stryker's SPY PHI device. Both patients experienced anastomotic leakage, with one having a grade 2 leak and the other a grade 1 leak. Fortunately, conservative measures proved successful in managing these complications and there was no conduit loss. The incorporation of additional venous anastomoses effectively relieves venous congestion in the gastric conduit after esophagectomy and prevent conduit loss, indicating its potential in improving patient outcomes.

Successful Undergoing Esophagogastric Anastomosis with Right Gastroepiploic Vessels Congenital Absence: A Case Report

A 60-year-old male farmer was admitted to the hospital with dysphagia for 2 months, and minimally invasive McKeown esophagectomy with lymphadenectomy was initially planned. However, congenital absence of the right gastroepiploic vessels (RGEVs) was blocked surgical procedure. Fortunately, we successfully performed esophagectomy and unconventional gastric remnant reconstruction without RGEVs, and intraoperative cervical venous superdrainage.

Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury

The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.

Restoring the perfusion of accidentally transected right gastroepiploic vessels during gastric conduit harvest for esophagectomy using microvascular anastomosis: a case report and literature review

BACKGROUND

Esophagectomy remains the standard treatment for esophageal cancer or esophagogastric junction cancer. The stomach, or the gastric conduit, is currently the most commonly used substitute for reconstruction instead of the jejunum or the colon. Preservation of the right gastric and the right gastroepiploic vessels is a vital step to maintain an adequate perfusion of the gastric conduit. Compromise of these vessels, especially the right gastroepiploic artery, might result in ischemia or necrosis of the conduit. Replacement of the gastric conduit with jejunal or colonic interposition is reported when a devastating accident occurs; however, the latter procedure requires a more extensive dissection and multiple anastomosis.

CASE PRESENTATION

A 61-year-old male with a lower third esophageal squamous cell carcinoma (cT3N1 M0) who received neoadjuvant chemoradiation with a partial response. He underwent esophagectomy with a gastric conduit reconstruction. However, the right gastroepiploic artery was accidentally transected during harvesting the gastric conduit, and the complication was identified during the pull-up phase. An end-to-end primary anastomosis was performed by the plastic surgeon under microscopy, and perfusion of the conduit was evaluated by the ICG scope, which revealed adequate vascularization of the whole conduit. We continued the reconstruction with the revascularized gastric conduit according to the perfusion test result. Although the patient developed minor postoperative leakage of the esophagogastrostomy, it was controlled with conservative drainage and antibiotic administration. Computed tomography also demonstrated fully enhanced gastric conduit. The patient resumed oral intake smoothly later without complications and was discharged at postoperative day 43.

CONCLUSION

Although the incidence of vascular compromise during harvesting of the gastric conduit is rare, the risk of conduit ischemia is worrisome whenever it happens. Regarding to our presented case, with the prompt identification of the injury, expertized vascular reconstruction, and a practical intraoperative evaluation of the perfusion, a restored gastric conduit could be applied for reconstruction instead of converting to more complicated procedures.