A gastric conduit is most frequently used for reconstruction in oesophageal surgery, and ischemia of the conduit is the most fragile aspect of the esophagogastric anastomosis with as consequence the anastomotic leakage. In order to avoid it, the concept of ischaemic conditioning of the stomach previous to surgery has been designed. The basis of ischemic conditioning is that interrupting vascularization of the stomach before making the anastomosis eases the gastric fundus adaptation to ischemic conditions. It consists of the interruption of the principal feeding arteries of the stomach (except the right gastroepiploic artery) weeks before esophagectomy. Previously published literature contemplates two different techniques: angiographic embolization or laparoscopic ligation or division of vessels. In this study, the anatomic and physio-pathologic background of ischemic preconditioning is described and the published current evidence is reviewed.

No abstract

Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence. Methods This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer. Results A 55 year-old female diagnosed with gastric adenocarcinoma. Tumor was 3 cm long, from esophago-gastric junction to subcardial region (cT3N1M0). Patient underwent perioperative chemotherapy and surgical intervention 6 weeks later. A laparoscopic superior polar gastrectomy was performed and D1+ lymphadenectomy. A laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of gastric pouch and two seromuscular flaps were dissected. Gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis. Seromuscular flaps were sewn overlapping the esophago-gastric anastomosis. Patient presented an optimal postoperative evolution, without heartburn, dysphagia neither vomiting. Conclusion The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.

Aim To present a video of a complete bilateral recurrent laryngeal nerve lymphadenectomy performed during minimally invasive esophagectomy using thoracoscopic video-assisted surgery in the prone position. Background and Methods Surgical treatment for esophageal cancer needs detailed lymphadenectomy. Indeed, the number of surgically dissected lymph nodes is important for staging accuracy and also determines patient’s prognosis, including those along the recurrent laryngeal nerve. However, recurrent laryngeal nerve dissection remains difficult and increases the appearance of postoperative complications. This is a video of a bilateral recurrent laryngeal nerve lymphadenectomy during thoracoscopic esophagectomy performed in the prone position in a female patient with esophageal cancer. Results A 75 year-old female was diagnosed with recurrent squamous cell middle third esophageal carcinoma. The patient had first been diagnosed eleven years ago, receiving chemoradiotherapy as a radical treatment. The patient achieved a complete response after treatment, which remained for eleven years. Eleven years later, during routine follow-up, tumor recurrence was identified in the middle third of the esophagus. After presentation in a Multidisciplinary Group the patient underwent minimally invasive McKeown esophagectomy. First, a video-assisted thoracoscopic surgery was performed in the prone position to mobilize the thoracic esophagus and complete a detailed mediastinal lymph node dissection, including infra-carinal lymph nodes, bilateral bronchial lymph nodes and also bilateral recurrent laryngeal nerve lymph nodes. Afterwards, the abdominal esophagus and lymph node dissection is performed using a laparoscopic approach, and also a left cervicotomy in the supine position. An assistance laparotomy was made to externalize the specimen and make the gastric conduit. A manual end-to end esophago-gastric anastomosis was executed and finally, a feeding jejunostomy tube was placed. The patient presented a benign postoperative course, introducing enteral nutrition and oral intake developing no complications, such as dysphonia, nor dysphagia and was discharged on the 8th postoperative day. The postoperative barium swallow radiography showed no leaks nor other complications and pathology report confirmed tumor free resection margins. Conclusion Detailed mediastinal lymph node dissection and exhaustive bilateral recurrent laryngeal nerve lymphadenectomy can be safely performed by minimally invasive surgery, as is shown in the video. The technique shown is feasible, achieves a complete lymph-node dissection and avoids postoperative complications such as dysphonia and recurrent laryngeal nerve palsy.

No abstract