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Preoperative imaging and prediction of oesophageal conduit necrosis after oesophagectomy for cancer. BJS 2017; 104: 1346-1354.

Published: 11th May 2017

Authors: P. Lainas, D. Fuks, S. Gaujoux, Z. Machroub, A. Fregeville, T. Perniceni et al.

Background

Oesophageal conduit necrosis following oesophagectomy is a rare but life‐threatening complication. The present study aimed to assess the impact of coeliac axis stenosis on outcomes after oesophagectomy for cancer.

Method

The study included consecutive patients who had an Ivor Lewis procedure with curative intent for middle‐ and lower‐third oesophageal cancer at two tertiary referral centres. All patients underwent preoperative multidetector CT with arterial phase to detect coeliac axis stenosis. The coeliac artery was classified as normal, with extrinsic stenosis due to a median arcuate ligament or with intrinsic stenosis caused by atherosclerosis.

Results

Some 481 patients underwent an Ivor Lewis procedure. Of these, ten (2·1 per cent) developed oesophageal conduit necrosis after surgery. Coeliac artery evaluation revealed a completely normal artery in 431 patients (91·5 per cent) in the group without conduit necrosis and in one (10 per cent) with necrosis (P < 0·001). Extrinsic stenosis of the coeliac artery due to a median arcuate ligament was found in two patients (0·4 per cent) without conduit necrosis and five (50 per cent) with necrosis (P < 0·001). Intrinsic stenosis of the coeliac artery was found in 11 (2·3 per cent) and eight (80 per cent) patients respectively (P < 0·001). Eight patients without (1·7 per cent) and five (50 per cent) with conduit necrosis had a single and thin left gastric artery (P < 0·001).

Conclusion

This study suggests that oesophageal conduit necrosis after oesophagectomy for cancer may be due to pre‐existing coeliac axis stenosis.

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Your comments

1 Comment

Antonio Manenti

3 weeks ago

We agree with Lainas et al. (1) about the importance of the vascular anatomy of the celiac artery (CA) in oesophageal surgery, to avoid post-operative complications, such as anastomotic leakage or more extended ischaemic necrosis of the gastric conduit. Considering the important role of the right gastro-epiploic artery, we report a particular anatomic condition of “radiologically-predominant” left gastro-epiploic artery (2).

We observed, in a 74-year-old patient with a cardio-oesophageal carcinoma, at a pre-operative angio-CT, anatomic variants: a common hepatic artery originating from the superior mesenteric trunk and a CA with its terminal “gastro-splenic” trunk giving rise to a big left gastro-epiploic branch. This artery directly continued with the right gastro-epiploic artery, which progressively reduced its size approximating to its origin from the common hepatic trunk. Calcified not-obstructing atherosclerotic plaques surrounded the orifices of the CA and of the superior mesenteric artery. The patient was treated with trans-hiatal oesophagectomy, complicated by ischaemic necrosis of the gastric conduit, as proved by a post-operative CT-angiography. In our opinion, the interruption of the left “predominant” gastro-epiploic artery was the precipitating factor.

This case suggests, in oesophageal surgery, a careful study of the gastric vascular supply, especially when anatomical variants of the celiac-mesenteric arterial network are associated with atherosclerosis, albeit clinically latent (3,4). These two conditions can hinder functional compensations to a blood supply modified by surgery. In these cases, pre-operatively interventional radiological procedures can improve the collateral circulation and intra-operatively controls with Doppler-US or fuorescent-green-indocyanine can guide the surgical strategy (5).

D. Mosca
G. Melegari
G. Manco
A. Manenti
A. Farinetti

Department of Surgery
University of Modena
Via Università, 4
41121 Modena
Italy
antonio.manenti@unimore.it

References:
1. Lainas P, Fuks D, Gaujoux S, Machroub Z, Fregeville A et al. Preoperative imaging and prediction of esophageal conduit necrosis after oesophagectomy for cancer. Br J Surg 2017; 104: 1346- 54.
2. Prudius V, Procàzka V, Pavlogkyz Z, Prudius D, Kala Z. Vascular anatomy of the stomach related to resection procedures strategy. Surg Radiol Anat 2017; 39: 433-40.
3. Buunen M, Rooijens PP, Smaal HJ, Kleinrensink GJ, van der Harst E, Tilanus HW et al. Vascular anatomy of the stomach related to gastric tube construction. Dis Esophagus 2008; 21: 272-
4. Marco Clement I, Martinez Barco A, Ahumada N, Simon C, Valderrama JM, Sanudo J et al. Anatomical variations of the celiac trunk : cadaveric and radiological study. Surg Radiol Anat 2013; 38: 501-10.
5. Zimmermann M, Liebl M, Schulze-Hagen M, Pedersoli F, Pfeffer J, Schmeding M et al. Preoperative embolization of the celiac axis or common hepatic artery before distal pancreatectomy with resection of the celiac axis. J Vasc Int Radiol 2017; 28: 60-3.