PS01.186: QUANTITATIVE PERFUSION EVALUATION AFTER GASTRIC TUBE RECONSTRUCTION USING FLUORESCENCE IMAGING

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 102-103 ◽  
Author(s):  
Sanne Jansen ◽  
Daniel De Bruin ◽  
Simon Strackee ◽  
Ed Van Bavel ◽  
Ton Van Leeuwen ◽  
...  
Keyword(s):  
Patient Outcome ◽  
Anastomotic Leakage ◽  
Fluorescence Imaging ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Contact Method ◽  
Fluorescent Intensity ◽  
Fluorescent Signal ◽  
Maximal Intensity ◽  
Quantitative Parameters

Abstract Background Poor fundus perfusion is seen as the major factor for the development of anastomotic necrosis, leakage and strictures. Quantitative imaging of tissue perfusion during reconstructive surgery, therefore, may reduce the incidence of complications. Imaging the fluorescense of intravenously administered fluorophores is an optical, non-contact method to image blood flow in real-time. However, quantitative parameters for perfusion evaluation are stil lacking. The objective of this study is to test fluorescence imaging derived quantitative parameters for perfusion evaluation of the gastric tube during surgery and to correlate these parameters to patient outcome in terms of anastomotic leakage. Methods This study included 22 patients (October 2015 - June 2016). Indocyanine green (ICG) was injected intravenously and the fluorescense intensity of the gastric tube was imaged for 2–3 minutes. At 4 locations, quantitative analysis of the fluorescent intensity over time was performed to obtain perfusion related parameters: the maximal intensity, mean slope and influx timepoint. These parameters were tested for significant differences between the four perfusion areas of the gastric tube (from normal to decreased perfusion) with a repeated ANOVA test. Furthermore, these parameters and the distance of the end of the gastroepiploic artery to the fundus and distance of the demarcation of the fluorescent signal to the fundus were compared with patient outcome in terms of anastomotic leakage development. Results The fluorescent signal could be detected in all analyzed patients (n = 20). Maximal intensity, mean slope and influx timepoint were significantly different between the base of the gastric tube and the fundus (P < 0.0001). While the distance of the watershed and the demarcation of ICG to the fundus varied between patients, the distance of the demarcation of ICG to the fundus was significantly higher in the three patients who developed anastomotic leakage (P < 0.0001). No allergic reactions on ICG were witnessed. Conclusion Intra-operative fluorescence imaging is feasible to visualize perfusion quantitatively in gastric-tube surgery, using the parameters maximal intensity, mean slope and influx timepoint. A low slope and a large distance between the fluorescence demarcation and the fundus were seen in patients who developed anastomotic leakage and could therefore allow for early risk stratification of necrosis. Disclosure All authors have declared no conflicts of interest.

PS01.190: FLEXIBLE GASTRIC TUBE: A NOBLE METHOD OF GASTRIC TUBE RECONSTRUCTION WITHOUT ANASTOMOTIC LEAKAGE

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 103-104
Author(s):  
Yasuaki Nakajima ◽  
Kenro Kawada ◽  
Yutaka Tokairin ◽  
Akihiro Hoshino ◽  
Takuya Okada ◽  
...  
Keyword(s):  
Anastomotic Leakage ◽  
Clinical Outcomes ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Circular Stapler ◽  
Anastomotic Site ◽  
Subtotal Esophagectomy ◽  
The Status ◽  
Greater Curvature ◽  
Gastric Tube Reconstruction

Abstract Background Anastomotic leakage is one of the most frequent and severe morbidities after esophagectomy. For preventing anastomotic leakage, it is important to design a gastric tube with sufficient blood supply and to perform precise anastomosis at a well-conditioned site. We herein show our method of gastric tube reconstruction and evaluate the outcome. Methods Seven hundred and forty-six esophageal carcinoma patients who received subtotal esophagectomy with gastric tube reconstruction via the retrosternal route between 1994 and 2017 were enrolled in the present study. Although we previously used a greater curvature gastric tube with a 4 cm in diameter (narrow group), since 2000, a ‘flexible gastric tube,’ which was designed on an individual basis with the aim of preserving the vascular plexus in the center of the anterior and posterior stomach wall to the maximum possible extent in order to supply a sufficient amount of blood to the tip of the gastric tube was used (flexible group). Cervical esophagogastric end-to-side anastomosis using the circular stapler was performed during the whole period. The clinical outcomes were compared between the two groups. Results Anastomotic leakage was observed in 36 (4.8%) patients. While 24 of 155 (15.5%) patients showed anastomotic leakage in the narrow group, 12 of 591 (2.0%) patients showed anastomotic leakage in the flexible group and the clinical outcomes were significantly improved. Conclusion Our method of gastric tube reconstruction helped to improve the rate of anastomotic leakage after esophagectomy. At present, we are investigating the status of the blood flow using an ICG fluorescence method and by measuring the degree of oxygen saturation and hemoglobin using a new non-invasive monitoring tool during the operation. Postoperative assessments of the anastomotic site are performed using endoscopic examinations. We herein report the results of these assessments. Disclosure All authors have declared no conflicts of interest.

PS01.187: ASSESSMENT OF THE BLOOD SUPPLY USING THE INDOCYANINE GREEN FLUORESCENCE METHOD AND POSTOPERATIVE ENDOSCOPIC EVALUATION OF ANASTOMOSIS DURING ESOPHAGECTOMY

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 103-103
Author(s):  
Hiroyuki Kitagawa ◽  
Jun Iwabu ◽  
Tsutomu Namikawa ◽  
Kazuhiro Hanazaki
Keyword(s):  
Indocyanine Green ◽  
Anastomotic Leakage ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Fluorescence Method ◽  
Control Group ◽  
Indocyanine Green Fluorescence ◽  
Conventional Procedure ◽  
Endoscopic Assessment ◽  
Gastric Tube Reconstruction

Abstract Background Postoperative anastomotic leakage is a severe complication after gastric tube reconstruction during esophagectomy. The aim of this study was to evaluate the usefulness of postoperative endoscopic assessment of anastomosis and its correlation with intraoperative indocyanine green (ICG) fluorescence assessment of the gastric tube. Methods We retrospectively reviewed 72 consecutive patients who underwent gastric tube reconstruction using the ICG fluorescence method during esophagectomy. Forty-six patients underwent the ICG line-marking method (LMM group; ICG before gastric tube creation). The other 26 underwent the conventional procedure and comprised the control group (ICG after gastric tube creation). Postoperative endoscopic assessment (PEA) of anastomosis was performed 7 days after surgery and results were classified as follows: grade 1 (normal or partial white coat), grade 2 (ulcer comprising less than half the circumference), and grade 3 (ulcer comprising more than half the circumference). Results Anastomotic leakage occurred in 7 of 72 patients (9.7%). The incidence of anastomotic leakage in the LMM group was tended to be lower than those in the control group (6.5% vs. 15.4%; P = 0.244). Of the 40 patients who underwent PEA, 3 (7.5%) had leakage. PEA grading was significantly associated with anastomotic leakage (P < 0.001). Better intraoperative ICG assessment was significantly associated with better endoscopic assessment grade (P = 0.041). Conclusion Intraoperative ICG assessment of the gastric tube was associated with PEA grading on anastomosis during esophagectomy. Disclosure All authors have declared no conflicts of interest.

VS03.01: QUANTITATIVE IMAGING OF CHANGE IN MICROCIRCULATION BY SIDESTREAM DARK FIELD MICROSCOPY (SDF) AFTER ESOPHAGECTOMY

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 47-48
Author(s):  
Sanne Jansen ◽  
Daniel De Bruin ◽  
Mark I Van Berge Henegouwen ◽  
Ton Van Leeuwen ◽  
Suzanne Gisbertz
Keyword(s):  
Anastomotic Leakage ◽  
Gastric Tube ◽  
Average Velocity ◽  
Venous Return ◽  
Conflicts Of Interest ◽  
Dark Field ◽  
Vessel Density ◽  
Flow Index ◽  
High Morbidity ◽  
Sidestream Dark Field

Abstract Description Anastomotic leakage is one of the most severe complications after esophageal resection with gastric tube reconstruction. Impaired perfusion of the gastric fundus is seen as the main contributing factor for this complication. Transection of the left gastric and gastro-epiploic artery and veins results in compromised perfusion in the fundus area which can result in anastomotic dehiscence (5–20%), relating to high morbidity and mortality (3–4%). The main objective of this observational study is to evaluation gastric tube microcirculation with Sidestream Darkfield Microscopy (SDF). Method This study included 22 patients (October 2015 - June 2016). Intra-operative microscopic images of gastric tube microcirculation were obtained with SDF directly after reconstruction. Using software (AVA2.0), the following parameters were evaluated: average velocity (μm/sec), Microvascular Flow Index (MFI), Total Vessel Density (TVD), Perfusion Vessel Density (PVD), Proportion of Perfused Vessels (PPV) and the De Backer Score (DBS), to assess change in perfusion. Results SDF accurately visualized and evaluated microcirculation in all patients. A SDF-stabilizer was used to create stable images. The average velocity decreased significantly towards the fundus (P = 0.001). Also, MFI, PVD and PPV were significantly lower towards the fundus, compared to the base of the gastric tube (P = 0.0002). No differences in TVD and DBS were observed, which was associated to the observed vessel dilation in the fundus-area. This vessel dilation proposes that compromised venous return may play an important role in the development of necrosis and leakage. Three patients developed anastomotic leakage. Conclusion This is the first study presenting quantitative microcirculation imaging with SDF of the gastric tube. Velocity, MFI, TVD and PPV were accurate parameters to observe change in perfusion after reconstruction. Also, vessel dilation in the fundus suggests a role for venous return in the development of ischemia. Quantitative microcirculation with SDF could allow for intra-operative early risk stratification, and, potentially, can result in a reduction of anastomotic leakage. Disclosure All authors have declared no conflicts of interest.

PS01.175: EVALUATION OF ASSOCIATIONS BETWEEN GASTRIC TUBE PREPARATION METHODS AND THE INCIDENCE OF CERVICAL ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY FOR THORACIC ESOPHAGEAL CANCER

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 99-99
Author(s):  
Yutaka Miyawaki ◽  
Hiroshi Sato ◽  
Sinich Sakuramoto ◽  
Koujun Okamoto ◽  
Shigeki Yamaguchi ◽  
...  
Keyword(s):  
Anastomotic Leakage ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Multivariate Logistic Regression Analysis ◽  
Esophageal Reconstruction ◽  
Peripheral Blood Flow ◽  
Thoracic Esophageal Cancer ◽  
Preparation Methods ◽  
Brinkman Index ◽  
The Difference

Abstract Background In esophageal reconstruction, the gastric tube (GT) is superior in elevation and handiness of the maneuver; therefore, GT is most often selected as a reconstruction conduit. Although some leakages from esophagogastric anastomoses are induced by ischemic or congested peripheral blood flow in the reconstruction conduits, the association between the GT and the incidence of anastomotic leakage (AL) is unclear. Methods Between February 2013 and September 2017, 188 consecutive patients who underwent an esophagectomy with GT reconstruction were enrolled in this cohort study. We performed GT reconstructions using narrow gastric tubes (Gr.N) until May 2016, which is when we began preparing and using stretched GTs (Gr.S). We retrospectively evaluated the incidence of AL. Results AL occurred in 29 of 188 (15.4%) patients, and the frequency of AL occurrence in Gr.S was lower than that in Gr.N (P = 0.034). Sex, body mass index, Brinkman index, and presence of hypertension or anemia were significantly associated with AL (P = 0.033, 0.041, 0.003, 0.030, and 0.042, respectively). The multivariate logistic regression analysis suggested that the type of GT used and the Brinkman index were independent risk factors for AL (P = 0.016 and 0.020, respectively). Conclusion Our results demonstrated that the difference in the GT preparation method was an independent risk factor for AL after cervical esophagogastrostomy. We suggest that the method of GT preparation could contribute to a reduction of AL after esophagectomy. Disclosure All authors have declared no conflicts of interest.

PS02.069: CERVICAL GASTROPLASTY ANASTOMOSIS AFTER ESOPHAGECTOMY: INDOCYANINE GREEN FLUORESCENCE IMAGING EVALUATION AND TECHNICAL SURGICAL ASPECTS

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 140-140
Author(s):  
Flavio Takeda ◽  
Ulysses Ribeiro Jr ◽  
Rubens Sallum ◽  
Julio Mariano Rocha ◽  
Andre Duarte ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Fluorescence Imaging ◽  
Conflicts Of Interest ◽  
Visual Assessment ◽  
Gastric Conduit ◽  
Linear Stapler ◽  
Recurrent Nerve ◽  
Imaging Evaluation ◽  
Indocyanine Green Fluorescence ◽  
Surgical Aspects

Abstract Description One of the most frequent complication after esophagectomy is the anastomotic leakage, which is a determiming factor of morbidity and mortality after surgical treatment. The best location for the esophagogastric anastomosis (cervical or intra-thoracic) has been topic of discussion for many years, and surgical aspects as resected margins, recurrent nerve trauma and mainly the vascularization of the anastomosis. In this video we performed a cervical gastroplasty anastomosis (McKeown), side-to-side, stapled (linear stapler) with a thin gastric tube conduit, and after that we aimed to determine the feasibility and usefulness of indocyanine green (ICG) fluorescence imaging to evaluate the gastric conduit perfusion during an esophagectomy. After pulling up the gastric conduit trhought the mediastinum and after performing the cervical anastomosis, 5 mg of ICG was in jected as a bolus and visual assessment of the blood supply of the gastric conduit was seen. This patient was a 63 years old, male, with adenocarcinoma of esophago-gastric junction (Siewert II) underwent to neoadjuvant quimiotherapy (FOLFOX regimen) and submitted after 3 cycles to esophagectomy (thoracoscopy and laparoscopy). No fistula was found in post operative follow-up, and either complications. Disclosure All authors have declared no conflicts of interest.

PS01.168: IS IT POSSIBLE TO PREVENT GASTRIC TUBE NECROSIS FOLLOWING ESOPHAGECTOMY?

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 97-97
Author(s):  
Katsunori Nishikawa ◽  
Yujiro Tanaka ◽  
Yuichiro Tanishima ◽  
Shunsuke Akimoto ◽  
Fumiaki Yano ◽  
...  
Keyword(s):  
Gastric Tube ◽  
Assessment Tool ◽  
Imaging System ◽  
Conflicts Of Interest ◽  
Tissue Perfusion ◽  
Early Postoperative Period ◽  
Partial Replacement ◽  
Full Thickness ◽  
Intraoperative Assessment ◽  
Vascular Insufficiency

Abstract Background Gastric tube necrosis (GN) following esophagectomy is a rare, but critical and life threatening complication. Unlike anastomotic leakage due to local ischemia, GN involves extensive full thickness ischemia resulting from vascular insufficiency. Most cases of GN need total or partial replacement of gastric tube. Although quantitative assessment of tissue perfusion during esophageal surgery contributed to reduce the incidence of postoperative anastomotic complications, GN remains a serious complication to be solved. Methods Data were collected retrospectively from 271 patients who underwent esophagectomy and gastric tube reconstruction at a single center between 2008 and 2018, in which cases of GN were identified. Gastric mobilization was mainly performed laparoscopically using a hand-assisted maneuver. The short gastric and left gastric arteries were divided, and the right gastric and gastroepiploic arteries were both preserved. The gastric tube 3.5 cm in width was created along the greater curvature. Intraoperative assessment of perfusion of the gastric tube was performed using our novel Thermal Imaging System (TIS) in all patients. Quantitative tissue perfusion scores defined as anastomotic viability index (AVI) were calculated at various points from the anastomosis. Results The inpatient mortality rate was 1.8% (n = 5). Anastomotic leak (AL) developed in 8.8% (n = 24) of the study group. The mean AVI score of cases with AL was 0.58, which was significantly lower than that without AL (0.71, P < 0.001). GN occurred in two patients (0.7%). The AVI score of the both GN cases were relatively high at 0.74 and 0.82. In one of the cases, circumferential full thickness ischemia 10 cm in length from the esophagogastric anastomosis was revealed by contrast CT scans and endoscopy, which was later identified to be due to severe vascular impairment. Conclusion TIS can be used as a reliable intraoperative assessment tool for perfusion of the gastric tube. We assume that most AL would be caused by delayed anastomotic healing due to poor vascularization of the gastric tube. On the other hand, obvious difference in AVI scores between AL and GN may indicate the involvement of different etiology. Given that development of GN seemed to be caused by acute failure in vascularization during the early postoperative period. Disclosure All authors have declared no conflicts of interest.

Quantification of the micoperfusion of gastric tube using fluorescence imaging with Indocyanine green

2021 ◽  
Author(s):  
P von Kroge ◽  
M Reeh ◽  
JR Izbicki ◽  
O Mann ◽  
A Duprée
Keyword(s):  
Indocyanine Green ◽  
Fluorescence Imaging ◽  
Gastric Tube

FA05.03: EFFECT OF EPHEDRINE ON GASTRIC CONDUIT PERFUSION MEASURED BY LASER SPECKLE CONTRAST IMAGING (LSCO) AFTER ESOPHAGECTOMY: A PROSPECTIVE IN-VIVO COHORT STUDY

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 10-10
Author(s):  
Sanne Jansen ◽  
Daniel De Bruin ◽  
Simon Strackee ◽  
Mark I Van Berge Henegouwen ◽  
Ton Van Leeuwen ◽  
...  
Keyword(s):  
Anastomotic Leakage ◽  
Gastric Tube ◽  
Gastric Conduit ◽  
Laser Speckle ◽  
Contrast Imaging ◽  
Laser Speckle Contrast Imaging ◽  
Speckle Contrast ◽  
Before And After ◽  
Gastric Tube Reconstruction

Abstract Background Compromised perfusion due to ligation of arteries and veins in esophagectomy with gastric tube reconstruction often (5–20%) results in necrosis and anastomotic leakage, which relate to high morbidity and mortality (3–4%). Ephedrine is used widely in anesthesia to treat intra-operative hypotension and may improve perfusion by the increase of cardiac output (CO) and mean arterial pressure (MAP). This study tests the effect of ephedrine on perfusion of the future anastomotic site of the gastric conduit, measured by Laser Speckle Contrast Imaging (LSCI). Methods This prospective, observational, in-vivo pilot study includes 26 patients undergoing esophagectomy with gastric tube reconstruction from October 2015 to June 2016 in the Academic Medical Center (Amsterdam). Perfusion of the gastric conduit was measured with LSCI directly after reconstruction and after an increase of MAP by ephedrine 5 mg. Perfusion was quantified in flux (LSPU) in four perfusion locations, from good perfusion (base of the gastric tube) towards decreased perfusion (fundus). Intra-patient differences before and after ephedrine in terms flux were statistically tested for significance with a paired t-test. Results LSCI was feasible to image gastric microcirculation in all patients. Flux (LSPU) was significantly higher in the base of the gastric tube (791 ± 442) compared to the fundus (328 ± 187) (P < 0.001). After administration of ephedrine, flux increased significantly in the fundus (P < 0·05) measured intra-patients. Three patients developed anastomotic leakage. In these patients, the difference between measured flux in the fundus compared to the base of the gastric tube was high. Conclusion This study presents the effect of ephedrine on perfusion of the gastric tissue measured with LSCI in terms of flux (LSPU) after esophagectomy with gastric tube reconstruction. We show a small but significant difference between flux measured before and after administration of ephedrine in the future anastomotic tissue (313 ± 178 vs. 397 ± 290). We also show a significant decrease of flux towards the fundus. Disclosure All authors have declared no conflicts of interest.

scholarly journals Calcification of arteries supplying the gastric tube increases the risk of anastomotic leakage after esophagectomy with cervical anastomosis

2016 ◽  
Vol 8 (12) ◽  
pp. 3551-3562 ◽  
Author(s):  
Liang Zhao ◽  
Gefei Zhao ◽  
Jiagen Li ◽  
Bin Qu ◽  
Susheng Shi ◽  
...  
Keyword(s):  
Anastomotic Leakage ◽  
Gastric Tube ◽  
Cervical Anastomosis

PS01.174: AN EXAMINATION OF OUTCOMES AFTER ANTE-THORACIC ROUTE WITH RIGHT HEMICOLON RECONSTRUCTION AFTER ESOPHAGECTOMY.

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 99-99
Author(s):  
Yuki Hirata ◽  
Hirofumi Kawakubo ◽  
Shuhei Mayanagi ◽  
Kazumasa Fukuda ◽  
Rieko Nakamura ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Average Duration ◽  
Oral Intake ◽  
Recurrent Nerve ◽  
Nerve Paralysis ◽  
Recurrent Nerve Paralysis ◽  
Reconstruction Group ◽  
Group 1

Abstract Background In our institute, we usually use gastric tube for reconstruction organ after esophagectomy. When we can’t use gastric tube, we use right hemi-colon with ante-thoracic route. Previously, we reconstructed by 1-step after esophagectomy, but from 2012, we have done by 2-step for reduce postoperative complications. Methods We enrolled 15 esophageal cancer patients who underwent esophagectomy and right hemicolon reconstruction between April 2004 and December 2016. Results The average age of 15 patients is 67.3. The reasons of using right hemicolon are as follows; post gastrectomy 13, stomach double cancer 2. The reasons of gastrectomy are as follows; gastric cancer 8, duodenum cancer 1, gastric ulcer 4. The average duration from gastrectomy to esophagectomy is 12.5 year. We reconstructed by 1-step for 5 patients, and after 2012, we reconstructed by 2-step for 10 patients. Anastomotic leakages were found in 2 cases (40.0%) in 1-step reconstruction group, and 3 cases (20.0%) in 2-step reconstruction group. In 1-step reconstruction group, 1 case occurred multiple anastomotic leakages and DIC, and another 1 case was found necrosis of reconstructive colon. In 2-step reconstruction group, we found 1 case of major leakage and 1 case of recurrent nerve paralysis and 2 cases of postoperative pneumonia. However, there were no case of tracheotomy. The incidence of pneumonia did not differ between the two groups. And the term of postoperative oral intake tend to shorter in 2-step reconstruction group (P = 0.06). 2 severe postoperative complications (Clavian-Dindo V or IVa) cases were found in 1-step reconstruction group, on the other hand, 2 cases severe complications (CD IIIa) in 2-step reconstruction group. Conclusion In the case of using right hemicolon as a reconstructive organ, 2-step reconstruction approach is useful and superior from the viewpoints of postoperative complications. Disclosure All authors have declared no conflicts of interest.

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