Department of General Surgery, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
BMC Surg. 2022 Jul 28;22(1):292. doi: 10.1186/s12893-022-01728-3.
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.
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.
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.
食管癌或食管胃结合部癌的标准治疗仍然是食管切除术。目前，胃（胃管）是重建的最常用替代品，而不是空肠或结肠。保留右胃和胃网膜右血管是维持胃管充足灌注的重要步骤。这些血管的损伤，特别是胃网膜右动脉的损伤，可能导致管腔缺血或坏死。当发生灾难性事故时，报告使用空肠或结肠间置替换胃管；然而，后者需要更广泛的解剖和多个吻合。
一名 61 岁男性，患有下段食管鳞状细胞癌（cT3N1 M0），接受新辅助放化疗后部分缓解。他接受了食管切除术和胃管重建。然而，在采集胃管时意外切断了胃网膜右动脉，在提拉阶段发现了这一并发症。整形外科医生在显微镜下进行了端端吻合，并用 ICG 镜评估了管腔的灌注情况，显示整个管腔的血供充足。我们根据灌注试验结果继续用再血管化的胃管进行重建。尽管患者术后发生了轻微的食管胃吻合口漏，但通过保守引流和抗生素治疗得到了控制。计算机断层扫描也显示了完全增强的胃管。患者后来顺利恢复口服饮食，无并发症，并于术后第 43 天出院。
虽然在采集胃管时发生血管损伤的发生率较低，但发生管腔缺血的风险令人担忧。就我们提出的病例而言，通过及时发现损伤、专业的血管重建以及术中对灌注的实际评估，可以应用修复后的胃管进行重建，而不必采用更复杂的手术。
