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How do we manage the gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery? Report of two cases and a review of the literature.

Konishi Y, Suzuki K, Wada H, Watanabe H, Ogura H, Sugamori Y, Bashar AH, Yamashita K, Kobayashi T, Kazui T - World J Surg Oncol (2007)

Bottom Line: Handling of the RGEA during gastrectomy in these patients may cause lethal complications, which sometimes reduces the feasibility of curative dissection of lymph nodes at the base of the graft.To avoid the potentially fatal coronary event during gastrectomy, safe handling of the conduit including preparations for injuries and prevention of vessel spasm was performed in both cases, accompanied by an adequate monitoring of the systemic circulation.Therefore, this operation should be carried out with careful management by both gastrointestinal and cardiovascular surgeons.

View Article: PubMed Central - HTML - PubMed

Affiliation: First Department of Surgery, Hamamatsu University School of Medicine 1-20-1, Handayama, Hamamatsu, 431-3192, Japan. konishi@hama-med.ac.jp

ABSTRACT

Background: Recently, the right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative arterial graft. Unfortunately, an increased incidence of gastric cancers has been reported after CABG using the RGEA. Handling of the RGEA during gastrectomy in these patients may cause lethal complications, which sometimes reduces the feasibility of curative dissection of lymph nodes at the base of the graft.

Case presentations: We describe two cases of gastric cancer undergoing gastrectomy after CABG with the use of RGEA. To avoid the potentially fatal coronary event during gastrectomy, safe handling of the conduit including preparations for injuries and prevention of vessel spasm was performed in both cases, accompanied by an adequate monitoring of the systemic circulation. Intraoperative frozen section examination showed no lymph node metastasis around the graft in any of the cases; therefore, complete lymph node dissection at the base of the graft was not undertaken. No complications occurred during the operation. In addition to these two cases, twenty-four cases reported in the literatures were reviewed (a total of 26 cases). Ten early and 16 advanced gastric cancers were included. Among the 16 advanced gastric cancer cases, an alternative graft was employed in 8 due to the resection of an original graft to complete lymph node dissection. Mere handling of a graft often caused lethal complications suggesting that the operation should be completed by isolation of the graft. A pedicled graft harvesting via the ante-gastric route was popular. However, a skeletonized harvesting with resection of the pyloric branches of the RGEA would be better because this would interrupt the original lymph flow, which could eliminate the need for lymph node dissection and graft isolation. Among the 10 cases having early gastric cancers, 6 were found within 1.5 years after CABG. Early detection in these 6 cases was possible due to the use of gastric fiberscopic examination before and after CABG, which gave them opportunities to receive a less extensive operation such as endoscopic mucosal resection.

Conclusion: Adequate intraoperative care as well as an optimal lymph node dissection considering the graft harvesting method at the first CABG leads to successful gastrectomy after CABG using the RGEA graft. Therefore, this operation should be carried out with careful management by both gastrointestinal and cardiovascular surgeons.

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Preoperative angiography via celiac artery showed that the RGEA graft remained well patent.
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Figure 1: Preoperative angiography via celiac artery showed that the RGEA graft remained well patent.

Mentions: The patient was a 76-year-old man. In November 1999, he underwent three- vessel CABG. A postero-lateral branch of the coronary artery was grafted by a pedicled RGEA. In July 2004, he presented to a private hospital because of tarry stool 5 years after CABG. By gastric fiberscopic examination, he was diagnosed to have an early gastric cancer (IIc) located in the lower anterior area of the stomach and was transferred to our hospital for gastrectomy in October. Preoperative angiography showed that the RGEA graft remained well patent (Figure 1).


How do we manage the gastrectomy for gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery? Report of two cases and a review of the literature.

Konishi Y, Suzuki K, Wada H, Watanabe H, Ogura H, Sugamori Y, Bashar AH, Yamashita K, Kobayashi T, Kazui T - World J Surg Oncol (2007)

Preoperative angiography via celiac artery showed that the RGEA graft remained well patent.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1884156&req=5

Figure 1: Preoperative angiography via celiac artery showed that the RGEA graft remained well patent.
Mentions: The patient was a 76-year-old man. In November 1999, he underwent three- vessel CABG. A postero-lateral branch of the coronary artery was grafted by a pedicled RGEA. In July 2004, he presented to a private hospital because of tarry stool 5 years after CABG. By gastric fiberscopic examination, he was diagnosed to have an early gastric cancer (IIc) located in the lower anterior area of the stomach and was transferred to our hospital for gastrectomy in October. Preoperative angiography showed that the RGEA graft remained well patent (Figure 1).

Bottom Line: Handling of the RGEA during gastrectomy in these patients may cause lethal complications, which sometimes reduces the feasibility of curative dissection of lymph nodes at the base of the graft.To avoid the potentially fatal coronary event during gastrectomy, safe handling of the conduit including preparations for injuries and prevention of vessel spasm was performed in both cases, accompanied by an adequate monitoring of the systemic circulation.Therefore, this operation should be carried out with careful management by both gastrointestinal and cardiovascular surgeons.

View Article: PubMed Central - HTML - PubMed

Affiliation: First Department of Surgery, Hamamatsu University School of Medicine 1-20-1, Handayama, Hamamatsu, 431-3192, Japan. konishi@hama-med.ac.jp

ABSTRACT

Background: Recently, the right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative arterial graft. Unfortunately, an increased incidence of gastric cancers has been reported after CABG using the RGEA. Handling of the RGEA during gastrectomy in these patients may cause lethal complications, which sometimes reduces the feasibility of curative dissection of lymph nodes at the base of the graft.

Case presentations: We describe two cases of gastric cancer undergoing gastrectomy after CABG with the use of RGEA. To avoid the potentially fatal coronary event during gastrectomy, safe handling of the conduit including preparations for injuries and prevention of vessel spasm was performed in both cases, accompanied by an adequate monitoring of the systemic circulation. Intraoperative frozen section examination showed no lymph node metastasis around the graft in any of the cases; therefore, complete lymph node dissection at the base of the graft was not undertaken. No complications occurred during the operation. In addition to these two cases, twenty-four cases reported in the literatures were reviewed (a total of 26 cases). Ten early and 16 advanced gastric cancers were included. Among the 16 advanced gastric cancer cases, an alternative graft was employed in 8 due to the resection of an original graft to complete lymph node dissection. Mere handling of a graft often caused lethal complications suggesting that the operation should be completed by isolation of the graft. A pedicled graft harvesting via the ante-gastric route was popular. However, a skeletonized harvesting with resection of the pyloric branches of the RGEA would be better because this would interrupt the original lymph flow, which could eliminate the need for lymph node dissection and graft isolation. Among the 10 cases having early gastric cancers, 6 were found within 1.5 years after CABG. Early detection in these 6 cases was possible due to the use of gastric fiberscopic examination before and after CABG, which gave them opportunities to receive a less extensive operation such as endoscopic mucosal resection.

Conclusion: Adequate intraoperative care as well as an optimal lymph node dissection considering the graft harvesting method at the first CABG leads to successful gastrectomy after CABG using the RGEA graft. Therefore, this operation should be carried out with careful management by both gastrointestinal and cardiovascular surgeons.

Show MeSH
Related in: MedlinePlus