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Ann Thorac Surg 2006;81:2318-2320
© 2006 The Society of Thoracic Surgeons

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How to do it

Preoperative Laparoscopic Ligation of the Left Gastric Vessels in Preparation for Esophagectomy

Department of Surgery and Medicine, University of California Irvine Medical Center, Orange, California

Accepted for publication May 10, 2005.

^_* Address correspondence to Dr Nguyen, 101 The City Dr, Bldg 55, Rm 106, Orange, CA 92868 (Email: ninhn{at}uci.edu).

	Abstract

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Anastomotic leak is a major cause for morbidity after esophagectomy. The cause is believed to be ischemia of the gastric conduit. Preoperative embolization of the left gastric vessels in preparation for esophagectomy has been shown to improve collateral blood flow of the gastric conduit and may reduce the frequency of anastomotic dehiscence after esophagectomy. This report describes the technique of laparoscopic division of the left gastric vessels in 9 patients who underwent pre-esophagectomy staging laparoscopy. Our initial experience demonstrates that laparoscopic ligation of the left gastric artery is a safe alternative to embolization and can be performed in conjunction with staging laparoscopy for patients with esophageal cancer.

	Introduction

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Esophagectomy is a complex abdominal and thoracic operation that can be associated with catastrophic postoperative complication, such as leak at the esophagogastric anastomosis [1]. The stomach is the preferred conduit for esophageal replacement and the major cause for leak is believed to be ischemia of the gastric conduit. In construction of the gastric conduit, three of the five major blood vessels to the stomach are divided. The left gastric, the short gastric, and the left gastroepiploic vessels are divided during mobilization of the gastric conduit leaving the right gastric artery and the right gastroepiploic preserved as the remaining blood supply. With abrupt interruption of these vessels, there is a decrease in vascularization toward the apex of the gastric conduit, which is often the site of the anastomosis. Decreased perfusion to the tip of the gastric conduit results in impaired healing of the anastomosis and can lead to dehiscence and stricture.

In an effort to minimize ischemia of the gastric conduit during esophagectomy, Akiyama and colleagues [2] reported the novel approach of preoperative embolization of the left and right gastric vessels and splenic vessels. Akiyama and colleagues [2] reasoned that embolization would interrupt the blood supply to the gastric fundus, thereby inducing collateral blood flow through the right gastroepiploic artery. Indeed at the ensuing esophagectomy, Akiyama and colleagues [2] found that the blood flow to the proximal gastric conduit was significantly higher in patients receiving preoperative embolization therapy compared with patients who did not.

We routinely perform laparoscopic staging for esophageal cancer patients whose roentgenographic imaging suggests resectability [3]. In January 2004, we introduced the technique of laparoscopic ligation of the left gastric vessels during our staging laparoscopy. This report reviews our experience with 9 patients who underwent laparoscopic ligation or division of the left gastric vessels in preparation for esophagectomy.

	Technique

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Between January 2004 and February 2005, laparoscopic staging was performed on 9 patients in preparation for esophagectomy. Laparoscopic staging consisted of diagnostic laparoscopy, esophagoscopy, placement of a jejunostomy tube, and ligation or division of the left gastric vessels.

Laparoscopic staging was performed using five abdominal trocars (three 5-mm and two 11-mm). All quadrants of the abdominal cavity, peritoneal surfaces and the liver were systematically inspected for metastatic deposits, and a biopsy was performed on all suspicious lesions. The origin of the celiac axis was evaluated by dividing the gastrohepatic omentum to expose the left gastric vessels (Fig 1). Findings of matted, firm, enlarged, or fixed lymphadenopathy at the celiac axis were considered locally advanced, unresectable disease, and a biopsy was obtained for confirmation when possible. Lymphadenopathy at the celiac axis region without fixation was considered resectable disease. Routine lymph node biopsy was not performed at the time of staging laparoscopy. The left gastric vessels were either divided using the linear stapler (Figs 2A, 2B), or were ligated without division with a single interrupted suture. The Endostitch (US Surgical Corp, Norwalk, CT) was utilized to facilitate ligation of the left gastric vessels.

View larger version (90K): [in this window] [in a new window]   Fig 1. Laparoscopic exposure of the left gastric vessels (arrow).

View larger version (104K): [in this window] [in a new window]   Fig 2. (Top) Laparoscopic division of the left gastric vessels with the linear stapler. (Bottom) Divided left gastric vessels with the use of staple-line reinforcement material (arrow).

	Comment

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Anastomotic leak is the most feared complication after esophagectomy. Briel and colleagues [4] reported that conduit ischemia occurred in 9.2% of the patients, and a leak occurred in 10.9% of the 393 consecutive esophagectomy patients performed at the University of Southern California, not significantly different from reports of 2 decades previously. Anastomotic leak after esophagectomy increases the mortality of the procedure [5]. Pickleman and colleagues [1] reported that the mortality in patients with anastomotic leak after esophagectomy was 50%. Briel and colleagues [4] reported that the mortality for anastomotic leak was 11.6%, and that 37% of all deaths after esophagectomy at their institution occurred as a result of conduit ischemia, leak, or a combination of these factors. Ischemia of the conduit led to stricture formation in 48% of patients who had an ischemic conduit and 47% of patients who had an anastomotic leak [4]. Taken together, these data support the need for novel preoperative or intraoperative therapy during esophagectomy that may reduce anastomotic complications secondary to ischemia.

The mechanism for ischemia of the gastric conduit is the abrupt disruption of three of the five blood vessels to the stomach during mobilization and construction of the gastric conduit. In an effort to minimize ischemia of the apex of the gastric conduit, Akiyama and colleagues [2] reported the use of percutaneous preoperative embolization of the left gastric, right gastric, and splenic arteries through the femoral artery. The splenic artery was embolized to indirectly interrupt the left gastroepiploic and short gastric vessels. Akiyama and colleagues [2] found that the mean blood flow in the gastric conduit was greater in the preoperative embolization group (n = 54 patients) compared with the control group (n = 25 patients). Most striking, only 2% of patients receiving preoperative embolization therapy had anastomotic leaks compared with 8% of patients in the control group [2]. The most frequent complications associated with preoperative embolization therapy were fever, abdominal pain, and vomiting, probably as a result of splenic infarcts [2].

The novel treatment of preoperative interruption of the blood vessels to the stomach is a concept of promoting collateral blood flow. We routinely perform laparoscopic staging of patients with esophageal cancer to obtain accurate staging prior to surgical resection and reported that findings at the laparoscopic stage avoided unnecessary laparotomy in 10 of 33 (30%) patients [3]. This report demonstrates that preoperative interruption of the left gastric vessels can be safely performed at the same time as staging laparoscopy, which adds approximately 5 minutes to the procedure. The left gastric vessels can be either completely divided using a surgical stapler or ligated with a single interrupted suture. Disadvantages of dividing the left gastric vessels at the time of surgical staging are possible formations of local adhesions and the additional cost for the surgical stapler. Ligation without division of the left gastric vessels potentially reduces adhesions in the celiac region. In addition, this procedure would be costly for surgeons who do not routinely perform laparoscopic staging prior to esophagectomy.

We do not advocate preoperative embolization of the splenic and right gastric vessels. Rather, the right gastric and the right gastroepiploic vessels should be maintained as the main blood supply to the gastric conduit. One additional option to further disrupt the blood supply to the gastric fundus during laparoscopic staging is to mobilize the gastric fundus and divide the short gastric vessels. However, dense adhesion formation can be observed after division of the short gastric vessels, which makes the subsequent esophagectomy difficult, particularly if the planned esophagectomy is minimally invasive. Although in this report, the mean time interval between staging laparoscopy with interruption of the left gastric vessels and esophagectomy was 12 days, the optimal time period between these two procedures may still need to be evaluated.

In summary, preoperative interruption of the sinestral arterial supply to the stomach is a concept aimed at inducing an ischemic insult to the proximal stomach prior to esophagectomy, thus leading to development of collateral blood flow. Embolization therapy described to accomplish this task has complications related to splenic infarction [2]. In this article, we described an alternative technique of laparoscopic ligation of the left gastric vessels performed in conjunction with staging laparoscopy for patients with esophageal cancer. This technique is relatively simple and adds no morbidity to the staging procedure. A larger study is needed to confirm our finding of an association between preoperative ligation of the left gastric vessels and reduction in the rate of anastomotic dehiscence. In addition, further studies are needed to determine the optimal time interval between the time for ligation of the left gastric vessels and esophagectomy.

	References

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1. Pickleman J, Warson W, Cunningham J, Fisher SG, Gamelli R. The failed gastrointestinal anastomosisan inevitable catastrophe. J Am Coll Surg 1999;188:473-482.[Medline]
2. Akiyama S, Kodera Y, Sekiguchi H, et al. Preoperative embolization therapy for esophageal operation J Surg Oncol 1998;69:219-223.[Medline]
3. Nguyen NT, Roberts PF, Follette DM, et al. Evaluation of minimally invasive surgical staging for esophageal cancer Am J Surg 2001;182:702-706.[Medline]
4. Briel JW, Tamhankar AP, Hagen JA, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosisgastric pull-up versus colon interposition. J Am Coll Surg 2004;198:536-542.[Medline]
5. Wilson SE, Stone R, Scully M, Ozeran L, Benfield JR. Modern management of anastomotic leak after esophagogastrectomy Am J Surg 1982;144:95-101.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John Lee Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nguyen, N. T. Articles by Wilson, S. E. Search for Related Content PubMed PubMed Citation Articles by Nguyen, N. T. Articles by Wilson, S. E. Related Collections Esophagus - cancer