Distal gastric tube resection with preservation of the right gastroepiploic artery for gastric tube cancer: a case report

Background The incidence of gastric tube cancer is increasing because of improved survival rates in patients with esophageal cancer treated by esophagectomy. Total resection of the gastric tube is expected to be highly curative, but it is associated with a higher risk of severe postoperative complications. Herein we report a case of early gastric tube cancer that was successfully treated by distal gastric tube resection with preservation of the right gastroepiploic artery (RGEA). Case presentation An 82-year-old man was diagnosed as having gastric tube cancer, B-12-O, Type 0-IIc, T1b, N0, M0, cStage IA (Japanese Classification of Gastric Carcinoma). Upper gastrointestinal endoscopy showed a Type 0-IIc lesion measuring 30 mm in length in the lower part of the gastric tube, and histopathological examination of biopsy specimens revealed the features of poorly differentiated adenocarcinoma. The primary lesion could not be identified by computed tomography, and there was no obvious lymph node metastasis or distant metastasis. Considering that total resection of the gastric tube would have been highly invasive and that the gastric tube cancer was at a relatively early stage, we performed distal gastric tube resection with preservation of the RGEA. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. There has been no recurrence during the 17 months of follow-up. Conclusion We successfully treated a patient with gastric tube cancer by distal gastric tube resection with preservation of the RGEA. This treatment strategy may be acceptable for patients with early gastric tube cancer without lymph node metastasis, considering the balance between the surgical invasiveness and curability of the tumor.

VASCULAR ANATOMY OF GREATER OMENTUM IN MIDDLE AGE ADULTS

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.

Simultaneous Vascular Reconstruction and Cervical Anastomosis in McKeown Esophagectomy

A stomach was considered ineligible to be an ideal conduit conventionally if its right gastroepiploic artery (RGEA) were injured. However, both sufficient blood flow and good venous return are crucial to the success of reconstruction. And there lacks robust evidence regarding the surgical techniques of reconstructing RGEA and right gastroepiploic vein (RGEV) and performing cervical anastomosis with gastric conduit simultaneously. Herein, we summarized the key surgical techniques for simultaneous vascular reconstruction and gastric conduit anastomosis in McKeown esophagectomy.