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For McKeown esophagectomy, hand-sewn and mechanical esophagogastric anastomosis techniques have been improved for constructing esophagogastrostomy. However, postoperative anastomosis-related complication rates remain high in patients undergoing cervical anastomosis. Here, we report an original and reliable hand-sewn cervical tunnel esophagogastric anastomosis technique to maximally reduce cervical anastomotic leakage and stricture rates after McKeown esophagectomy. The key features and innovations of cervical tunnel esophagogastric anastomosis are the right gastroepiploic artery as the center for the esophagogastric anastomosis to reduce ischemia, sufficient width of the anastomotic site for anastomosis without stricture, enfolding of the anastomotic site by the tunnel, and tension- and rotation-free anastomosis.

Idiopathic spontaneous intraperitoneal hemorrhage is both rare and potentially fatal. The incidence of gastroepiploic artery rupture, especially a non-aneurysmal rupture, is extremely low. We report the case of an elderly woman who was mistakenly diagnosed with procedure-related bleeding after gastroscopy. A 0.3 cm polyp was identified and removed during the procedure. The patient later developed shock due to which gastroscopy was repeated; however, no unusual findings were observed. Therefore, abdominopelvic computerized tomography was performed and gastroepiploic artery rupture was detected. Transcatheter arterial embolization was immediately performed without laparotomy, without any complications. The bleeding was controlled, and the patient was discharged after embolization. It is important to acknowledge the possibility of spontaneous rupture of the visceral arteries in elderly individuals with hypertension or atherosclerosis, especially in the event of sudden abdominal pain or shock immediately after an endoscopic procedure. This is the first case report of idiopathic spontaneous rupture of the right gastroepiploic artery successfully managed by transcatheter arterial embolization in South Korea.

Background and aim of the study Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). Methods Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. Results The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. Conclusions Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

BACKGROUND Total arterial revascularization is associated with increased patency and long-term efficacy and decreased perioperative morbidity and mortality and incidence of cardiac-related events and sternal wound infection compared with conventional coronary artery bypass surgery (CABG), in which the left internal mammary artery (LIMA) is typically grafted to the left anterior descending artery with additional saphenous vein grafts often used. This study determined whether these favorable clinical results could be realized at the authors’ institute. AIM To summarize the early efficacy and clinical experience of individualized total arterial coronary artery bypass grafting surgery. METHODS CABG was performed on 35 patients with non-single-vessel coronary artery disease by adopting total arterial grafts at Fourth Affiliated Hospital of Harbin Medical University between April 2016 and December 2019. LIMA was used in 35 patients, radial artery (RA) was used in 35 patients, and right gastroepiploic artery (RGEA) was used in 9 patients. Perioperative complications were observed, short-term graft patency rate was followed-up, and quality of life was assessed. RESULTS All patients underwent off-pump coronary artery bypass and the surgeries were successful. All of them were discharged without any complications or deaths. During the follow-up, it was found that patients’ angina symptoms were relieved and New York Heart Association classification for cardiac function was class I to class II. A total of 90 vessels were grafted with no occlusion for internal mammary artery, three occlusions for RA, and one occlusion for RGEA. CONCLUSION The individualized total arterial strategy based on the vessels targeting individual anatomic characteristics can achieve complete revascularization with satisfactory short-term grafting patency rate.

Endoscopic ultrasonography has become a routine procedure in clinical practice and is widely accepted as a safe procedure. Previous studies have reported that severe bleeding rarely occurs even when performing fine-needle aspiration biopsy. Severe hemorrhage following non-interventional endoscopic ultrasonography has never been reported. We herein report a case of hemorrhagic shock due to hemoperitoneum caused by a ruptured right gastroepiploic artery consequent to a diagnostic endoscopic ultrasonography. The patient was administered two antithrombotic agents. An extensive diagnostic workup contributed to the correct diagnosis, which led to a successful treatment by transcatheter arterial embolization. Endoscopists should be aware of this rare, but potentially fatal, adverse event of endoscopic ultrasonography.

The variability of artery and vein topography of greater omenta from 20 corpses of middle age adults was investigated by applying the anatomical and morphometric methods. The right and left gastroepiploic arteries supply the greater omentum with blood. In 80% of the cases studied these arteries form the superior arterial arch, in 15% of the cases they are not connected, and in 5% of the cases they form anastomosis through the right and left lateral branches, thus, forming the middle arterial arch of the greater omentum. In 10% of the cases, the left gastroepiploic artery is located in the thick of the posterior plate of the greater omentum. The right gastroepiploic artery branches into central, right medial, intermediate and lateral arteries and in 10% left additional artery. The right gastroepiploic artery and vein are longer in men (16.95 ± 5.5 cm) that in women (15.77 ± 2.9 cm). The outer diameter of these vessels is larger in women: 0.24 ± 0.03 cm of arteries and 0.27 ± 0.03 cm of veins. The central artery is the longest and widest of all omental branches. The area of the central artery is more preferred for flaps in quadrangular and triangular shapes of the greater omentum. The branches of the right gastroepiploic artery supply blood to the right half of the greater omentum and reach the lower edge of its free part. The left half of the greater omentum is supplied by the branches of the left gastroepiploic artery, namely by the left medial, intermediate and lateral arteries, which do not reach the lower edge of the free part of the omentum. In 10% of the cases, the superior left part of the omentum is additionally supplied with blood by the splenic artery. On such case of blood vessels presence, it can serve as a source for obtaining a flap. One vein accompanies the artery of the same name. All the veins of the omentum have a larger diameter than the arteries. In 15% of the cases greater omentum is quadrangular, in 25% of the cases is triangular and in 60% it is of irregular shape with two or more parts. In the one-part omentum, the left and right parts have the same blood supply. At the two-part structure, the right half is in more favourable condition in terms of the blood supply that enables to recommend its usage in transplantation surgery.

We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting. We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared. In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09). Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.

Background We evaluated the mid-term outcomes and angiographic patency of redo coronary artery bypass grafting (CABG). Methods Of 2,851 patients who underwent isolated CABG at Seoul National University Hospital from 2000 to 2017, 88 underwent redo CABG. Patients' mean age at redo CABG was 66.0±8.0 years. The mean interval between the first-time and redo CABG was 113.0±62.4 months. The mean follow-up duration was 86 months. Early and mid-term clinical outcomes were evaluated. Angiographic patency rates were evaluated early (1-2 days), 1 year, and 5 years after surgery. Comparative analyses between on-pump and off-pump CABG were also performed. Results The culprits for reoperation were previous grafts (65.6%), native coronary vessels (17.8%), and both (16.7%). Off-pump CABG was performed in 75 cases (85.2%), and the mean number of distal anastomoses was 1.8±0.8. The saphenous vein (39.7%) was used most frequently, followed by the right internal thoracic artery (28.4%), right gastroepiploic artery (21.3%), left internal thoracic artery (7.8%), and radial artery (2.8%). Operative mortality was 1.1%. The overall survival, cumulative incidence of cardiac death, and cumulative incidence of major adverse cardiac events were 71.3%,12.0%, and 23.3% at 5 years after surgery, respectively. The overall angiographic patency rates were 95.7%, 90.1%, and 92.2% on early, 1-year, and 5-year angiograms, respectively. The angiographic patency rates of saphenous vein grafts were 93.1%, 85.6%, and 91.3% on early, 1-year, and 5-year angiograms, respectively. No significant differences in clinical outcomes or angiographic patency rates were observed between the on-pump (n=13) versus off-pump (n=75) groups. Multivariable analysis revealed that age (hazard ratio [HR], 1.07; p=0.005) and chronic kidney disease (HR, 3.85; p=0.001) were risk factors for all-cause mortality. Conclusion Redo CABG could mostly be performed using the off-pump technique and did not show increased operative mortality and morbidities.

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.

Gastroepiploic aneurysms are rare. We report the case of a 74-year-old man who presented with temporary loss of consciousness and abdominal pain. Computed tomography revealed a ruptured right gastroepiploic artery aneurysm. His vital signs improved after extracellular fluid infusion; hence, we performed transcatheter arterial embolization. There were no postoperative complications, and the patient was discharged on the 15th day of hospitalization. Ruptured abdominal aneurysms are often fatal and should be considered in patients with symptoms of anemia and abdominal pain. Currently, minimally invasive transcatheter arterial embolization had been designated as the preferred treatment option because of effectiveness in both diagnosis and treatment. Thus, we report a case of ruptured right gastroepiploic artery aneurysm treated by transcatheter arterial embolization, thereby preventing an emergency surgery.

Introduction The right gastroepiploic artery (RGEA) is used in coronary artery bypass grafting (CABG). However, the treatment of gastric cancer after CABG using the RGEA is complex, because stopping coronary blood flow from the RGEA may cause lethal myocardial ischemia. Adequate treatment must strike a balance between the curability and safety. Case Presentation The patient was a 79-year-old man with advanced gastric cancer who had previously undergone CABG with the RGEA. It was impossible to perform curative gastrectomy with preservation of the RGEA. Thus, percutaneous coronary intervention was performed to revascularize the native right coronary artery. The patient then started chemotherapy using oxaliplatin and S-1. After 4 courses of chemotherapy, the patient underwent robotic distal gastrectomy with D2 lymphadenectomy, including regional lymph node dissection around the RGEA. The RGEA was cut after a clamp test confirmed that there was no ST change. Conclusion In patients who develop gastric cancer after CABG using the RGEA, percutaneous coronary intervention of the native coronary artery is useful when resection of the RGEA is required to dissect the No. 6 lymph node. Robotic gastrectomy is a surgical option in such cases.

For three patients with isolated right coronary artery disease who had drug resistance and were intolerant to interventional therapy, simple transabdominal small incision bypass grafting of the right gastroepiploic artery and the posterior descending branch of the right coronary artery was conducted without cardiopulmonary. All three patients were discharged smoothly without complications, and were followed up for three months, during which time the myocardial bridges were unobstructed and the cardiac functions were good. The surgery needs no thoracotomy and the injury is small, and avoids influences of sternum and pericardium adhesion on other cardiac surgery in the future. The risk of median sternotomy can be avoided for patients undergoing reoperation for coronary artery bypass surgery.

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.

Background Pancreaticoduodenectomy after esophageal resection is technically difficult, because blood flow of the gastric conduit should be preserved. Celiac axis stenosis (CAS) is also a problem for pancreaticoduodenectomy, because arterial blood supply for the liver comes mainly through the collateral route from the superior mesenteric artery (SMA) via the gastroduodenal artery (GDA). Herein, we report the case of a patient with pancreatic head cancer who underwent a pancreaticoduodenectomy after esophagectomy with concomitant CAS. Case presentation A 76-year-old man with pancreatic head cancer was referred to our department. He had a history of esophagectomy with retrosternal gastric conduit reconstruction for esophageal cancer. Computed tomography showed severe CAS and a dilated collateral route between the SMA and the splenic artery (SPA). We prepared several surgical options depending on the intraoperative findings, and performed radical pancreaticoduodenectomy with concomitant resection of the distal gastric conduit. The right gastroepiploic artery (RGEA) of the remnant gastric conduit was fed from the left middle colic artery (MCA) with microvascular anastomosis. Despite CAS, when the GDA was dissected and clamped, good blood flow was confirmed, and the proper hepatic artery did not require reconstruction. The patient was discharged on postoperative day 90. Conclusions We successfully performed radical pancreaticoduodenectomy after esophagectomy with concomitant CAS, having prepared multiple surgical options depending upon the intraoperative findings.

In patients with a reconstructed gastric tube, the right gastroepiploic artery is a very important feeding artery of the tube, which must be preserved when performing a pancreaticoduodenectomy. A 76-year-old man with a reconstructed gastric tube underwent pancreaticoduodenectomy for distal bile duct carcinoma. On postoperative day 8, he had an arterial hemorrhage from a drain, apparently from a ligation of the anterior superior duodenal artery. He, therefore, underwent stent-graft placement in the gastroduodenal artery. The stent-grafts were temporarily occluded, and the gastric tube was necrotizing. However, thrombolytic therapy allowed the stent-grafts to reopen and prevented gastric tube necrosis. We believe our case of stent-graft implantation in the gastroduodenal artery is the first of this kind to successfully prevent lethal necrosis of the gastric tube.

Background Segmental arterial mediolysis (SAM) is a rare, nonatherosclerotic, noninflammatory arteriopathy of unknown etiology, rarely involving omental artery (OA). No case reports have described left OA bleeding successfully treated with transarterial embolization (TAE) with coils. This report describes two cases of SAM-affected left OA bleeding successfully embolized using isolation technique with coils, recognizing the potential for the greater omentum to have arterial collateral network between OAs. Case presentation Case 1. A 55-year-old male with no significant past medical history presented with an acute abdomen. Contrast-enhanced computed tomography (CT) revealed possible hemorrhagic ascites involving the left portion of the greater omentum and dilated, stenotic change of the left OA with a possible hematoma. SAM-associated left OA bleeding was suspected. Given its acute-angled branching from a splenic artery or branch and long, tortuous catheter-trajectory, we used a triaxial catheter system. Left OA angiography revealed the proximal dilated, stenotic change and a distal pseudoaneurysm. Isolation was successfully performed with coils. Because he had no abdominal pain or progressive anemia, he was discharged on hospital day 5. Neither recurrence nor new SAM-associated findings were observed during two-years of follow-up. Case 2. A 60-year-old-man with no significant past medical history presented with an acute abdomen. CT revealed similar finding as Case 1. SAM-associated left OA bleeding was suspected. Left OA angiography revealed proximal dilated, stenotic change with distal occlusion. Despite having no signs of active bleeding, review of the CT and angiography findings suggested the left OA as the bleeding site. Given proximal embolization at this point could lead to incomplete hemostasis or rebleeding via the arterial collateral network between OAs, an attempt was made to navigate the microcatheter into the distal side beyond the occlusion. Distal left OA angiography confirmed that the distal OA over the occlusion was intact and directly communicated with a right OA arising from right gastroepiploic artery. The SAM-associated lesion was successfully isolated with coils. Because he had no abdominal pain or progressive anemia, he was transported to another hospital on hospital day 3. Neither recurrence nor new SAM-associated findings were observed during two-years follow-up. Conclusion SAM can involve left OA and be controlled using an isolation technique with coils.

The hybrid esophagectomy is a procedure that combines an initial laparoscopic approach in which the gastric conduit is prepared preserving the right gastroepiploic artery, followed by a right thoracotomy for resection of the esophagus, gastric pull-up into the chest, and esophagogastric anastomosis. Critical surgical steps should be carefully respected to perform a safe operation.

We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy. Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO2: 0–99%) and total hemoglobin index (T-HbI: 0–1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared. The mean values of rSO2 at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO2 gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461). A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

Background Saphenous vein graft aneurysm (SVGA) is a rare complication after coronary artery bypass grafting; however, it may lead to fatal conditions. A redo sternotomy poses a high risk of injury to the patent graft. Case report A 59-year-old man with chest pain was diagnosed with a giant SVGA (67 mm) anastomosed to the right coronary artery (RCA) and compressing the right atrium. Considering the high risk of injury to a patent graft through the sternum, a surgical procedure was planned without redo sternotomy. Through an upper midline abdominal incision, redo bypass grafting was performed to the distal RCA using the right gastroepiploic artery, followed by resection of the aneurysm using the right anterior lateral thoracotomy approach. The postoperative course was uneventful. Conclusion In patients with an SVGA anastomosed to the right coronary system, our surgical strategy may be a useful alternative to redo sternotomy to avoid injury to the patent graft.

We have performed off-pump coronary artery bypass grafting and also performed early postoperative angiography to assess anastomosis accuracy and patency in most of our patients requiring surgical revascularization.Of 3083 patients who underwent isolated coronary artery bypass grafting between 1998 and 2017, 2919 patients (94.7%) underwent off-pump coronary artery bypass grafting. Conduits for distal anastomoses were left internal thoracic artery (n = 2764), right internal thoracic artery (n = 866), right gastroepiploic artery (n = 997), radial artery (n = 16), and saphenous vein (n = 1505). Since the introduction of transit-time flow measurement in 2000, we revised abnormal grafts intraoperatively. Early (≤7 days) angiography was performed in 2820 patients (96.6%) at 1.5 ± 1.2 postoperative days, and surgical intervention was performed based on angiographic findings.Operative mortality was 1.1% (32 of 2919). Average number of distal anastomoses was 3.2 ± 1.0. Intraoperative flowmetry-guided revision for distal anastomosis failures was performed in 109 of 8585 distal anastomoses (1.3%). Angiography showed an overall patency of 98.2% (8836 of 9001): 99.0% (5484 of 5540) for arterial and 96.9% (3352 of 3461) for venous conduits (P.001). Patency of venous conduits was 87.2% (231 of 265) for free grafts and 97.7% (3121 of 3196) for composite grafts (P = .001). After the introduction of transit-time flow measurement, patency of arterial conduits became significantly higher (97.2% vs 99.2%; P = .038); however, patency of free venous conduits was not significantly improved (86.0% vs 91.4%; P = .181). Early re-intervention according to angiographic findings was performed in 76 patients (2.7%). Reevaluation of graft patency before discharge in 31 who underwent revision of distal anastomoses showed improved patency (65.1% [56 of 86] vs 95.3% [82 of 86]; P.001).Intraoperative flowmetry and revision of abnormal grafts improved early arterial graft patency, and reoperation based on early angiographic findings may further improve graft patency at the time of discharge.

Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipeline™ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.

Background Hepatic artery thrombosis can lead to graft loss associated with severe hepatic infarction or bile duct ischemia. When anatomical hepatic artery reconstruction is impossible in liver transplantation or hepato-pancreatic biliary surgery, portal vein arterialization (PVA) is proposed as a salvage technique. Herein, we report our experience with a case that showed favorable clinical outcomes after partial PVA during living-donor liver transplantation (LDLT) because of difficulties in arterial reconstruction. Case presentation A 62-year-old woman with non-B, non-C liver cirrhosis complicated with hepatocellular carcinoma was being prepared for LDLT using an extended left lobe graft. The graft presented with two arteries (left hepatic artery, 2 mm; middle hepatic artery, 2 mm). The first anastomosis was performed using the recipient hepatic artery stumps, but no flow was detected on Doppler control because of thrombus formation. The next attempt was executed using the middle colic artery with a radial artery jump graft and the right gastroepiploic artery, but it led to the same result. Thus, the graft oxygen support by the standard arterial procurement was abandoned, and a shunt was created between the ileocecal artery and the vein to obtain PVA. Arteriography of the superior mesenteric artery showed that the shunt was relatively patent, and the portal vein was apparent. No biliary complication or liver abscess occurred postoperatively, and the patient presented with good liver function and no complications related to portal vein hypertension, nor liver fibrosis 18 months after the LDLT. Conclusion Partial PVA with a shunt created between the ileocecal artery and the vein is useful when arterial reconstruction is difficult during LDLT for preventing graft loss caused by severe hepatic infarction or bile duct ischemia.

Highlights • We presented a patient with gastric tube cancer who successfully underwent subtotal gastrectomy with intraoperative ICG fluorescence. • ICG fluorescence is useful for evaluating the flow of the gastric tube and helping to determine the operating method., Introduction Currently, the frequency of evaluating the flow of a reconstructed gastric tube using indocyanine green (ICG) fluorescence has been increasing. However, it has been difficult to decide on the operation method for patients with gastric tube cancer (GTC). We herein report a case in which ICG was effective in a patient with resection of GTC. Presentation of case An 83-year-old man underwent subtotal esophagectomy with gastric tube reconstruction via the retrosternal route for esophageal cancer and right hemicolectomy for ascending colon cancer 16 years earlier. Postoperatively, the proximal part of the gastric tube had poor blood flow. Therefore, the patient underwent proximal-side resection of the gastric tube. Thereafter, free jejunal graft reconstruction was performed. The patient had not developed recurrence at that point. Recently, the patient visited the hospital complaining of nausea and chest discomfort. Upper gastrointestinal endoscopy revealed a type 0-IIa + IIc lesion located around the pylorus. A biopsy showed adenocarcinoma. Based on these findings, the patient was diagnosed with gastric tube cancer (cT1bN0M0StageI). The invasion depth of the cancer was predicted to be widespread submucosal invasion. Therefore, the patient underwent surgery. Intraoperatively, we evaluated the flow of the gastric tube after clamping the right gastroepiploic artery using ICG fluorescence. As a result, the flow of the gastric tube was deemed insufficient. Consequently, subtotal gastrectomy was performed with preservation of the right gastroepiploic artery via Roux-en-Y reconstruction. Discussion ICG fluorescence is useful for evaluating the flow of the gastric tube helping to decide the operating method. Conclusion We herein report a case of subtotal gastrectomy for GTC using intraoperative ICG fluorescence.

Haemorrhagic events in patients diagnosed with coronavirus disease 19 (COVID-19) are infrequent but reports have accumulated since the beginning of the pandemic. The pathophysiological mechanisms are unclear, but endothelial damage secondary to systemic vasculitis and the onset of anticoagulation therapy, both associated with severe forms of the infection, have been proposed to play a role in the development of this complication. We present the case of a 66-year-old man who presented to the emergency department with acute abdominal pain, hypotension and decrease of consciousness, a few hours after being discharged after a prolonged hospitalisation of 26 days due to severe SARS-CoV-2 pneumonia. Initial resuscitation was carried out and, when haemodynamic stabilisation was achieved, a computed tomography scan showed contrast extravasation at the topography of the greater omentum. Urgent angiography revealing contrast extravasation originating in a pseudoaneurysm dependent on the right gastroepiploic artery was done, and embolisation with cyanoacrylate was performed at the bleeding point. Owing to persistent haemodynamic instability despite angiographic treatment and aggressive resuscitation, emergency laparotomy was indicated. Partial resection of the greater omentum was carried out and histopathologic examination showed a 5cm×4cm×6cm haematoma, with no signs of abnormalities such as aneurysm or malignancy. No rebleeding occurred. Spontaneous haemorrhage of the greater omentum associated with haemoperitoneum is a serious condition, with reported mortality rates exceeding 30%. This case highlights a very infrequent but potentially life-threatening complication in a patient diagnosed with COVID-19 on anticoagulation therapy.