"Layer-to-Layer" Esophagogastric Anastomosis Combined with Intrathoracic Esophageal Mucosal Extention in Patients with Esophageal and Cardia Cancer

Objective: To evaluate the clinical value of intrathoracic esophagogastric "layer-to-layer" anastomosis with esophageal mucosa extended varied in plane and to study the effective methods to prevent anastomotic leaking or stricture postoperatively. Methods: From May 1985 to December 2002, 2 240 esophageal and stomach cardia cancer patients treated by intrathoracic esophagogastric "layer-to-layer" anastomosis with esophageal mucosa extended varied in plane were retrospectively analyzed. Results: There was no anastomotic leaking and severe stricture in all above cases. Conclusion: Intrathoracic esophagogastric "layer-to-layer" anastomosis with esophageal mucosal extended varied in plane is an effective method to prevent anastomotic leaking and stricture postoperatively.

Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME

AIM To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular. METHODS Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NOsystem. In the 4 d after esophagogastric anastomosis creation, rats received medication(/kg intraperitoneallyonce daily: BPC 157(10 μg, 10 ng), L-NAME(5 mg), or L-arginine(100 mg) alone and/or combined or BPC 157(10 μg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage(sum of the longest diameters, mm), esophagitis(scored 0-5), weak anastomosis(m L H2 O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter(cm H2O), progressive weight loss(g) and mortality. Immediate effect assessed blood vessels disappearance(scored 0-5) at the stomach surface immediately after anastomosis creation. RESULTS BPC 157(all regimens) fully counteracted the perilous disease course from the very beginning(i.e., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening(with L-NAME administration) and amelioration(with L-arginine), either L-arginine amelioration prevails(attenuated esophageal and gastric lesions) or they counteract each other(L-NAME + L-arginine); with the addition of BPC 157(L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability(as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening(obtained with L-NAME administration that was counteracted); or amelioration(L-arginine + BPC 157-rats correspond to BPC 157-rats).CONCLUSION Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy.

INTRALUMINAL ELASTIC CIRCULAR LIGATION FOR ESOPHAGOGASTRIC ANASTOMOSIS(INCLUDING THE CLINICAL ANALYSES OF 100 CASES)

Between 1981 and 1988, 234 cases of cancerof the esophagus or gastric cardia were treatedby resection and intraluminal elastic circularligation for esophagogastric anastomosis. Thispresent study advances the results described inour earlier study. The details of technicalrefinements are here reported, based on the

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND Reflux esophagitis is a common postoperative complication of proximal gastrectomy.There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy.We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis(EGAA)can prevent postoperative reflux in a safe and feasible manner.To observe a novel method of EGAA to prevent postoperative reflux.METHODS Initially,we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis.This was done in order to better understand the anti-reflux function and mechanism.Next,we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy.Post-surgery,we monitored the structure and function of the reconstruction through imaging exams and gastroscopy.Finally,the patients were followed up to assess the efficacy of the anti-reflux effects.RESULTS Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma,providing a means to prevent the reverse flow of gastric fluids.Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy,with a mean operation time of 304.2±44.3 min.After the operation,the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux,three had mild reflux,and two had obvious reflux.The abdominal computed tomography examination showed a valve-like structure at the anastomosis.During followup,gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients.Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.CONCLUSION EGAA is a feasible and safe surgical method,with an excellent anti-reflux effect after proximal gastrectomy.

Combined laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal cancer： initial experience from China

Background Minimally invasive Ivor Lewis esophagectomy was usually performed with either hand-sewn or circular stapler anastomosis through a small thoracotomy or using a side-to-side stapler anastomotic technique. This study aimed to present our initial results of Ivor Lewis esophagectomy using a circular-stapled anastomosis with transoral anvil technique. Methods Six patients with esophageal cancer underwent minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-end anastomosis. The abdominal portion was operated on laparoscopically, and the thoracic portion was done using thoracoscopic techniques. A 25 mm anvil connected to a 90 cm long delivery tube was introduced transorally to the esophageal stump in a tilted position, the anvil head was then connected to circular stapler. The anastomosis was completed under direct thoracoscopic view. Results A total of six patients in this report successfully underwent total laparoscopic and thoracoscopic Ivor Lewis esophagectomy with a circular-stapled anastomosis using a transoral anvil. They were five male and one female patients, and had a mean age of 55 years （range, 38-69 years）. The thoracic and abdominal operations were successfully performed without any intraoperative complications or conversion to laparotomy or thoracotomy. The passage of the anvil head was technically easy and successful in all six cases. The mean overall operative time was （260_＋42） minutes （range, 220-300 minutes）, and the mean estimated blood loss was （520_＋160） ml （range, 130-800 ml）. Patients resumed a liquid oral diet on postoperative day seven. The median length of hospital stay was 17 days （range, 9-25 days）. The postoperative pathological diagnosis was esophageal squamous cell carcinoma in five patients and esophageal small cell carcinoma in one patient. Tumors were staged as T2NoMo in three cases, T2N1M0 in one case, and T3NoM0 in two cases. During the mean follow-up of 2.5 months （range, 2-4 months）, there were no intraoperative technical failure of the anastomosis or major postoperative complications such as leak or stricture. Conclusions The initial results of this small series suggest that minimally invasive Ivor Lewis esophagectomy for malignant esophageal tumor is technically feasible. However, further multi-center prospective studies and thorough evaluation are needed to evaluate the long-term results.