Search

Background: Pancreatic head resection following proximal gastrectomy jeopardizes the blood flow of the remnant stomach owing to right gastroepiploic conduit sacrifice, thereby necessitating total gastrectomy. However, owing to its high invasiveness, concomitant remnant total gastrectomy with pancreatectomy should be avoided as much as possible. Herein, we describe our experience of total pancreatectomy with right gastroepiploic conduit preservation in a patient with a history of proximal gastrectomy and reconstruction by jejunum interposition. Case presentation: A 78-year-old woman with a history of gastric cancer was followed up at our institute for multiple intraductal papillary mucinous neoplasm, and main pancreatic duct stricture in the pancreatic head was newly detected. The cystic lesion was extended to the pancreatic body. Proximal gastrectomy and reconstruction by jejunal interposition were previously performed, and the mesenteric stalk of the interposed jejunum was approached through the retrocolic route. We planned total pancreatectomy with right gastroepiploic conduit preservation. Following adhesiolysis, the interposed jejunum and its mesentery lying in front of the pancreas were isolated. The arterial arcade from the common hepatic artery to the right gastroepiploic artery was detached from the pancreas. Furthermore, the right gastroepiploic vein was isolated from the pancreas. The pancreatic body and tail were pulled up in front of the remnant stomach, and the splenic artery and vein were resected. The pancreatic body and tail were pulled out to the right side, and the pancreatic head was divided from the pancreatic nerve plexus to the portal vein. The jejunal limb for entero-biliary anastomosis was passed through the hole behind the superior mesenteric artery and vein, and gastrointestinal anastomosis using the antecolic route and Braun anastomosis were performed. Conclusions: To avoid remnant total gastrectomy, right gastroepiploic conduit preservation is an optional procedure for pancreatic head resection in patients who have undergone proximal gastrectomy with reconstruction by jejunal interposition. [ABSTRACT FROM AUTHOR]

Purpose: Surgical resection is the only curative treatment for pancreatic cancer. Arterial resection and reconstruction during pancreaticoduodenectomy for advanced pancreatic cancer remain controversial due to a high rate of complications. Methods: We report two cases of pancreatic cancer with hepatic artery resection and reconstruction using the right gastroepiploic artery during pancreaticoduodenectomy after neoadjuvant therapy. Results: The patients underwent pancreaticoduodenectomy with resection of the right hepatic and common hepatic arteries. Achieving direct anastomosis was difficult; therefore, we planned hepatic artery reconstruction using the right gastroepiploic artery. We performed the reconstruction using an interrupted suture with end-to-end anastomosis. The first patient developed a postoperative pancreatic fistula, while the postoperative course of the second patient was uneventful. However, there were no adverse events related to the arterial reconstruction. R0 resection was achieved, and postoperative computed tomography revealed good patency of the reconstructed artery. Conclusion: Hepatic artery reconstruction using the right gastroepiploic artery in pancreatic cancer might be technically safe and might become one of the alternative options. [ABSTRACT FROM AUTHOR]

A 64-year-old Thai woman underwent coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) for completely occluded left anterior descending artery (LAD) and mitral valve replacement with mechanical valve about a year ago. She presented with unstable angina. Three-dimensional computed tomography angiography (3DCTA) showed occlusion of all the grafts. The left subclavian artery had 99% stenosis. The patient underwent redo CABG via a minimally invasive direct approach. The chest was entered through the left fifth intercostal space. The right gastroepiploic artery (RGEA) and a small length of SVG were harvested. The RGEA was extended using the SVG with an end-to-end anastomosis and used to graft the LAD without cardiopulmonary bypass. The patient's postoperative course was uneventful. Postoperative 3DCTA revealed patent RGEA-SVG graft. Minimally invasive direct coronary artery bypass to LAD with RGEA is a useful alternative approach for redo CABG in patients with not much choice of conduits. [ABSTRACT FROM AUTHOR]

Background: The right gastroepiploic artery is commonly used in coronary artery bypass grafting. Appropriate strategies are required when performing upper abdominal surgeries after the right gastroepiploic artery has been used in coronary artery bypass grafting because compressing or injuring the graft may cause myocardial ischemia and fatal arrhythmias. To our knowledge, this is the first reported case of surgery for achalasia performed after coronary artery bypass grafting using the right gastroepiploic artery. We have discussed the surgical procedure and particular intraoperative considerations. Case presentation: A 62-year-old man who had undergone coronary artery bypass grafting using the right gastroepiploic artery presented with achalasia. Because medication and balloon dilation had been ineffective and he was having difficulty ingesting food, we performed a Heller-Dor procedure via laparotomy. The right gastroepiploic artery was not damaged during this surgery, and there were no perioperative cardiovascular complications. Adequate control of symptoms was achieved. Conclusions: When performing upper abdominal surgeries after coronary artery bypass grafting with the right gastroepiploic artery, it is necessary to investigate the patient carefully preoperatively and adapt the intraoperative procedure to minimize risk of injury to the graft and consequent cardiovascular complications. [ABSTRACT FROM AUTHOR]

The exceptional case of the right gastroepiploic artery (RGE) arising from the dorsal pancreatic (DP) artery in an individual affected by hepatocellular carcinoma is presented. This anatomic variant was demonstrated with a selective angiography of the common hepatic artery that showed a distinct DP artery branching from the injected artery. The DP artery gave off regular pancreatic branches and continued as a long and winding vessel that was identified as the RGE by its general course, the anterior epiploic branches arising from it, and the injection of the distal splenic artery, possibly via the anastomosis with the left gastroepiploic artery. The anatomy of the RGE has few variations, mostly limited to its origin from the superior mesenteric artery. Arising of the gastroepiploic artery from the DP artery has never been previously reported and represents an unexpected possible anatomic variant of which general and heart surgeons should be aware. In particular, this case is of interest in surgical procedures involving resection of the head of the pancreas, gastrectomies or coronary artery bypass grafting using the RGE. The embryology underlying the development of this anatomic variation is reviewed. [ABSTRACT FROM AUTHOR]

Purpose: Interruption of the right gastroepiploic artery (RGEA) used for prior coronary artery bypass grafting (CABG) may cause life-threatening myocardial ischemia during gastrectomy. This study investigated the cases treated in this department and pooled data in the literature to identify an adequate perioperative RGEA management strategy. Methods: Eight patients underwent gastrectomy after CABG with the RGEA. This study examined conditions, management of the RGEA, No. 6 lymph node metastasis, and complications of these cases and those in the pooled data. Results: Percutaneous coronary intervention or a redo CABG was performed in advance in 7 and 1 patients, respectively. The RGEA was resected for dissection of No. 6 lymph nodes in 6 patients. Five patients had lymph node metastasis. Thirty-seven patients from 40 combined cases (92.5 %) underwent total or distal gastrectomy, but 17 patients (42.5 %) had RGEA resection. Resections of the RGEA and No. 6 lymph node metastasis were significantly higher in patients with perioperative coronary management than in those without such management. Conclusion: Coronary and celiac angiography and coronary revascularization are prerequisites to prevent cardiac events during gastrectomy and dissection of No. 6 lymph nodes should be performed with resection of RGEA. Standard lymph node dissection should therefore be performed with a curative intent for all patients even those undergoing gastrectomy after CABG using RGEA. [ABSTRACT FROM AUTHOR]

We report an unusual case of intrapericardial diaphragmatic hernia 2 years after coronary artery bypass surgery with the right gastroepiploic artery. Herniation through the orifice created for the right gastroepiploic artery caused small bowel strangulation and secondary volvulus requiring extensive small bowel resection due to acute mesenteric ischemia. This case highlights the importance of careful operative management of coronary artery bypass surgery with the right gastroepiploic artery and increases awareness of this rare but potentially fatal complication. [ABSTRACT FROM AUTHOR]

To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) angiography for prediction of availability of the right gastroepiploic artery (RGEA) for coronary artery bypass grafting surgery (CABG). This study included 149 patients who underwent both preoperative MDCT angiography and exploratory laparotomy to harvest the RGEA for CABG. The prediction of availability of RGEA using the MDCT finding was evaluated by comparing it to an exploratory laparotomy evaluation of RGEA as a gold standard. The MDCT findings of atherosclerosis and diameter of the RGEA were analyzed. The atherosclerosis of other visceral branches was also analyzed for the detection of affecting factors to the availability for CABG. Atherosclerotic change of vessel was defined as findings including vessel wall calcification, luminal irregularity, aneurysmal change, and apparent atheroma. For statistical analysis, unpaired t-test and receiver operating curve analyses were used to compare the size of the RGEA, and the chi-square test was used to evaluate significant determinant factors of RGEA availability. In exploratory laparotomy, 21 out of 149 RGEAs were classified as inappropriate as a graft for CABG. The reason for inappropriateness was atherosclerosis of RGEA in 15 patients and small diameter in six patients. Sensitivity, specificity, positive predictive value and negative predictive value of MDCT angiography for assessing RGEA atherosclerosis was 60, 99.6, 94.7 and 96.1%, respectively. Atherosclerotic change of the RGEA itself was the only significant determinant factor for predicting the appropriateness of each RGEA. The mean diameter was 1.94 mm in 21 inappropriate RGEAs and 2.41 mm in 128 appropriate RGEAs. This difference was significant ( P = 0.001). The least diameter of appropriate RGEA was 1.4 mm on MDCT angiography, and the cut-off value determined by ROC analysis was 1.8 mm with 82.8% of sensitivity and 61.9% of specificity for inappropriate RGEA, and the area under the curve value was 0.729. MDCT is useful preoperative evaluation tool for RGEA availability. Findings of atherosclerosis of the RGEA and a small diameter on MDCT angiography suggest inappropriateness of the RGEA for CABG surgery. [ABSTRACT FROM AUTHOR]

We describe successful anesthetic management during living-donor liver transplantation in a 63-year-old man with previous coronary artery bypass grafting (CABG) that employed an in situ right gastroepiploic artery (RGEA). Anesthesia was maintained with 1.5% isoflurane in air/oxygen and fentanyl. A five-lead electrocardiogram, transesophageal echocardiogram, and pacing pulmonary artery catheter evaluated cardiac function. A pacing wire was inserted through the catheter to prepare for intraoperative severe bradyarrhythmia. Olprinone and nicorandil were continuously infused to prevent decrease in coronary arterial blood flow and the collapse of cardiac function. Avoiding disruption of circulation to coronary arteries through injury or spasm of the RGEA graft and preparing for cardiac insufficiency during liver transplantation of a patient with previous CABG using an in situ RGEA is critical. [ABSTRACT FROM AUTHOR]

Background and aims: The clinical significance of resectional surgery with reconstruction of the right hepatic artery for biliary malignancy remains unclear. Patients/methods: Between 1990 and 2004, six patients (5%) with cholangiocarcinoma and five patients (3%) with gallbladder carcinoma with possible involvement of the right hepatic artery underwent resectional surgery with reconstruction of the right-sided hepatic artery. The surgical procedures included extended left hemihepatectomy (n=4), left trisectionectomy (n=1), central bisegmentectomy (n=1), resection of anterior segment and inferior area of segment 4 (n=2), resection of segment 5 and inferior area of segment 4 (n=1), and extrahepatic bile duct resection (n=2). Segmental resection and reconstruction of the right (n=7), anterior (n=1), or posterior (n=3) hepatic artery was performed by end-to-end anastomosis (n=5), using the right gastroepiploic artery (n=4), the gastroduodenal artery (n=1), or an autologous venous graft (n=1). Results: There was no in-hospital mortality. Histopathological arterial involvement was present in seven patients, and the surgical margin was positive in five patients. The median survival was 23 months in R0 patients (n=6), while it was 13 months in R1 patients (n=5) (p=0.16). Conclusion: Reconstruction of the right hepatic artery was safely performed in patients with biliary malignancy. Arterial reconstruction can be indicated when the arterial involvement is the only obstacle to obtain negative surgical margins. [ABSTRACT FROM AUTHOR]

Objective: Since 1989, we have applied the right gastroepiploic artery (RGEA) as a third arterial conduit for coronary artery bypass grafting (CABG) and started to use sequential RGEA in 1992. We evaluated the feasibility and efficacy of sequential RGEA grafting in CABG. Methods: From December 1990 to January 2000, 46 patients underwent CABG with sequential RGEA. There were 42 male and 4 female patients with a mean age of 59±8.1 years. Mean postoperative follow-up period was 70 months. Results: The mean number of anastomoses was 3.7 per patient. Mean luminal diameter of the RGEA was 2.2±0.4 mm by preoperative angiography and 2.3±0.6 mm by intraoperative measurement. Patency of the sequential RGEA was 92%; proximal anastomosis 100%, distal anastomosis 86% (p=0.01). The 5-year actuarial survival and cardiac event-free rate were 91% and 93%, respectively. Conclusions: Sequential bypass using the RGEA is feasible, with excellent early and long-term results. The indication for sequential RGEA, however, needs careful anatomical consideration of both the luminal diameter of the RGEA and proximal stenosis of the target coronary arteries. [ABSTRACT FROM AUTHOR]

Copyright of Der Chirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Surgical & Radiologic Anatomy is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)