Allegheny General Hospital Minimally Invasive Surgery Center, Pittsburgh, PA 15212, USA.
Surg Endosc. 2011 Aug;25(8):2470-7. doi: 10.1007/s00464-010-1568-y. Epub 2011 Feb 8.
Cervical esophagogastric anastomotic disruption following transhiatal esophagectomy (THE) is a significant problem. Gastric tip ischemia is a primary cause of anastomotic failure. We examined gastric tip blood flow when laparoscopic "ischemic preconditioning" was attempted by selectively ligating the short gastric (SG) vessels or both the left and short gastric (LG/SG) vessels prior to THE.
Seventeen (25 kg) mongrel dogs underwent laparoscopy followed 3 weeks later by THE. Three groups were studied: control group = laparoscopy only, no preconditioning (n = 6); SG group = laparoscopic ligation of SG vessels only (n = 5); and LG/SG group = laparoscopic ligation of LG and SG vessels (n = 6). Tissue blood flow was assessed using the fluorescent microsphere method. The initial microsphere injections occurred prior to pneumoperitoneum and upon completion of the laparoscopy. At the second operation, transhiatal esophagectomy was performed and microsphere blood flow assessment occurred after induction of anesthesia, after mobilization of the stomach, and after completion of the cervical esophagogastric anastomosis. The animals were euthanized and regional gastric tissue was analyzed for microsphere estimates of blood flow. Differences in blood flow were evaluated using Student's t test.
The mean baseline gastric blood flow was 0.58 ml/min/g. After THE, the proximal gastric blood flow fell to 16% of baseline in control and 22% in SG, but was reduced to only 60% of baseline in LG/SG. This relative preservation of blood flow among the LG/SG group approached significance compared with the laparoscopy-only (control) group (P = 0.07). Ligation of SG vessels alone provided no preservation of proximal gastric blood flow following THE.
Preoperative "ischemic preconditioning" through ligation of both the short and left gastric vessels may achieve preservation of blood flow to the gastric tip. Preconditioning during laparoscopic staging of esophageal carcinoma may be considered to reduce anastomotic complications following esophagectomy.
经食管裂孔食管切除术（THE）后发生的颈段食管胃吻合口破裂是一个重大问题。胃尖部缺血是吻合口失败的主要原因。我们检查了在 THE 之前通过选择性结扎胃短血管（SG 血管）或左胃短血管和胃短血管（LG/SG 血管）尝试腹腔镜“缺血预处理”时胃尖部的血流。
17 只（25kg）杂种狗接受了腹腔镜检查，3 周后接受了 THE。研究了三组：对照组=仅腹腔镜检查，无预处理（n=6）；SG 组=仅腹腔镜结扎 SG 血管（n=5）；LG/SG 组=腹腔镜结扎 LG 和 SG 血管（n=6）。使用荧光微球法评估组织血流。初始微球注射在气腹前和腹腔镜完成时进行。在第二次手术中，进行经食管裂孔食管切除术，并在麻醉诱导后、胃游离后和完成颈段食管胃吻合后进行微球血流评估。动物被安乐死，分析胃的区域性组织以获得微球估计的血流。使用 Student's t 检验评估血流差异。
胃血流的平均基线值为 0.58ml/min/g。在 THE 之后，对照组的近端胃血流下降到基线的 16%，SG 组下降到 22%，但 LG/SG 组仅下降到基线的 60%。与仅腹腔镜（对照）组相比，LG/SG 组的相对血流保存接近显著（P=0.07）。单独结扎 SG 血管不能在 THE 后保存近端胃血流。
通过结扎胃短血管和左胃血管进行术前“缺血预处理”可能实现胃尖部血流的保存。在食管癌腹腔镜分期期间进行预处理可能有助于减少食管癌切除术后吻合口并发症。
