Arteriography of three models of gastric oesophagoplasty: the whole stomach, a wide gastric tube and a narrow gastric tube

Abstract

The esogastric anastomotic fistula,occurring after the replacement of esophagus by the stomach, is a post-operative complication always feared and awaited. Apart from other causes, there exist the anatomical dispositions notably the vascular and technical factors that stress this potential risk despite certain advantages of esophagogastroplasty. The goal of our study was to study the arterial distribution of the gastric transplants in order to identify the better modalities of their making. We used 39 stomachs taken from fresh cadavers of autochtone subjects. After a modeling treatment using three different techniques, they were subjected to a radiographic opacification of the right gastro-epiploic artery with sulphate of barium follow by an x-rays in incidence full-face (25 kv, 10 mAS). It was a matter of 15 entire stomachs (E.E.) with denudation of the small curvature, of 12 wide gastric tubes (W.T.) prepared according to the Akiyama technique modified and of 12 narrow tubes (N.T.) tubulized according to the Marmuse method. We studied the anastomotic type of the gastro-epiploic arterial circle according to the classification of Koskas, the collateral branches of the arterial circles of the gastric curvatures, the antral and corporeal anastomosis of these circles and the distribution anastomotic at the level of the summit of the anastomotic. Only 28 pieces (15 E.E., 8 W.T. and 5 N.T.) were able to be the object of a complete angiographic exploitation. The anastomosis of the arterial circle was type I in 64.1% of the cases, type II in 15.4% of the cases, type III in 15.4% of the cases and type IV in 5.1% of the cases. The average number of collateral branches originating from gastro-epiploic arterial circle was respectively 24, 17 and 22 for the E.E., the W.T. and the N.T. Only the two first ones presented collateral branches being borne of the small curvature circle. Fifty per cent of the N.T. did not possess any antral or corporeal anastomosis between the two arterial circles; some of them were even for a quarter of the W.T. In the case of gastric tubulization there existed an irrigation defect of the summit of the plasty for a third of the N.T. and a quarter of the W.T., despite a constant intramural bridge anastomosis between the two gastro-epiploic arteries. The usage of the entire stomach must be recommended for gastric oesophagoplasty; but when the operative indications require a resection of the small curvature it is preferable to use a wide gastric tube whose diameter respects the two left third of the initial width of the organ.

Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy

“…A knowledge of anatomy points to the variability of the gastroepiploic arcade as a possible cause. The work of Koskas and Gayet [39], Yamato et al [40], and more recently, Ndoye et al [41] warned against an inconstant vascular supply of the stomach, a fact that can be easily missed due to the loss of tactile and proprioceptive feedback during an MIO. Some authors have suggested modifying the procedure to include a minilaparotomy to deliver the stomach and fashion the conduit outside the body, promoting surgical sensory feedback, with a possible lower failure rate [8,25].…”

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

“…Atherosclerosis, a known cause of ischemia, has been reported to compromise the blood supply of the gastric tube and cervical anastomosis (9). It has also been reported that calcification of the aortic wall and supra-aortic arteries can be used to predict cardiovascular events (10).…”

“…To ensure the reliability of this study, another radiologist (J-J), who was also blinded to the data of patients, was also invited to evaluate CT imaging. The selection of investigated vessels was based on anatomic studies, which showed that the right gastroepiploic artery exclusively supplies the gastric tube and originates from the aorta via the celiac axis, common hepatic artery, and gastroduodenal artery (9,15). Furthermore, calcifications in the splenic and left gastroepiploic arteries were assessed because it has been reported that about 20% of the gastric tube is supplied by the left gastroepiploic arteries before divided (15).…”

Experimental model of laparoscopic gastric ischemic preconditioning prior to transhiatal esophagectomy

“…This also explains the increased occurrence of leak following cervical esophagogastric anastomosis, where the length of the gastric tube is necessarily extended and the gastric tip becomes more remote from its collateral blood supply [21].…”