Tracheal bifurcation located at proximal third of oesophageal length in Sprague Dawley rats of all ages

Levrat’s rat model is often the first choice for basic studies of oesophageal adenocarcinoma. The position of the tracheal bifurcation represents the preferred location for the high-intrathoracic anastomosis following oesophagectomy for cancer and is thus of importance in basic research of oesophageal adenocarcinoma. In addition, it is also the typical location for trachea-oesophageal fistulae in congenital oesophageal atresia and its rat model. We thus analysed whether the position of the tracheal bifurcation would be affected by a rat’s growth throughout life. We analysed absolute and relative carinal position of the tracheal bifurcation and its relationship to oesophageal length in two cohorts of Sprague Dawley rats (RjHan:SD) of both sexes: one consisted of 30 eight-week old rats and the other of 20 rats aged between 15 and 444 days. We analysed their relationship by Pearson’s r and univariate linear regression. Bootstrap confidence intervals were calculated for all calculated coefficients. Absolute carinal position correlated with oesophageal length in the eight-week old cohort (r=0.4, 95% CI: 0.08-0.71, p=0.015) and those of different ages (r=0.92, 95% CI: 0.77-0.96, p=0.0066). Absolute carinal position increased with oesophageal length in both cohorts (F(1,28)=5.56; p=0.0256 and F(1,18)=94.93; p<0.0001 respectively). Consequently, relative tracheal bifurcation position was not influenced by oesophageal length in both cohorts (F(1,28)=2.49; p=0.1257 and F(1,18)=1.92; p=0.183). Absolute carinal position increased with oesophageal length, but relative position remained constant at around 30% of proximal oesophageal length throughout life

One visceral artery may be enough; successful pancreatectomy in a patient with total occlusion of the celiac and superior mesenteric arteries

Abstract Background The anatomic variations of the visceral arteries are not uncommon. The liver arterial blood supply shows 50% variability between humans, with the most common anatomy being one hepatic artery arising from the celiac trunk and one pancreatico-duodenal arcade between the celiac trunk and the superior mesenteric artery. Occlusion of one artery are mostly asymptomatic but may become clinically relevant when surgery of the liver, bile duct or the pancreas is required. If these pathologies are not reversible, an oncologic pancreatic head resection cannot be performed. Case presentation We report the case of a 64-year-old Caucasian female patient with a locally advanced, resectable adenocarcinoma of the pancreas with complete atherosclerotic occlusion of the celiac trunk and the superior mesenteric artery. This vascular anomaly was missed on the preoperative imaging and became known postoperatively. A collateral circulation from a hypertrophic inferior mesenteric artery to the celiac trunk and the superior mesenteric artery compensated the blood supply to the visceral organs. The postoperative course was complicated by an elevation of the transaminases AST/ALT, which normalized under conservative treatment with alprostadil (prostavasin™) and anticoagulation, since angiographic recanalization failed. The patient recovered fully and was discharged at the 14th postoperative day. Two years later, she required endovascular repair of an aortic rupture during which the inferior mesenteric artery was preserved. Conclusion This case underlines the natural potential of the human body to adapt to chronic arterial malperfusion by creating a collateral circulation and supports the need for adequate preoperative imaging, including a proper arterial phase before upper abdominal surgery

Medicaroid robotic assisted surgery system: A feasibility study

The hinotori™ surgical robotic system, by Medicaroid (Medicaroid Corporation, Kobe, Japan), is a new robotic system for minimally invasive surgery. We aimed at evaluating its usability and accessibility in a preclinical setting. This was a preclinical feasibility study. Two groups of surgeons, one with three experienced robotic surgeons (group 1) and one with three robotic-surgery naive participants (group 2), performed the following tasks using the hinotori™ system in a simulated preclinical setting: console setup, docking, instrument exchange, undocking, and suturing. Each participant repeated each task three times. The time required for performing each repetition and the count of failed repetitions were the primary outcomes of the study. The subjectively perceived workload in performing the tasks, as measured by the NASA-TLX score, was the secondary outcome. The improvement of participants within the three repetitions as well as a comparison between the performances of group 1 and 2 were evaluated. The time required to perform each task decreased with repetitions for both groups, so did the subjective workload score. The time measures required to perform the tasks and the mental effort scores were comparable between the two groups for the console setup, docking, instrument exchange, and undocking tasks. The NASA-TLX score was also comparable between the two groups for the console setup and the emergency undocking tasks and decreased significantly within all tasks after the third repetition. The incidence of failed repetitions was higher in group 2 for the suturing task, however the difference was not statistically significant. The results confirmed the usability of the hinotori™ system in a preclinical setting for both highly trained surgeons and nonexperienced operators and its accessibility for both long-time users of other systems and first-time users

Robot-Assisted Minimally Invasive Esophagectomy with Intrathoracic Anastomosis (Ivor Lewis): Promising Results in 100 Consecutive Patients (the European Experience)

Background!#!Robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE procedures using the da Vinci Xi robotic system 4-arm technique.!##!Methods!#!Data of 100 consecutive patients with esophageal or gastro-esophageal junction carcinoma undergoing modified Ivor Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management. Intraoperative and postoperative complications were graded according to Esophagectomy Complications Consensus Group (ECCG) definitions.!##!Results!#!Mean duration was 416 min (±80); 70% of patients had an uncomplicated postoperative recovery. Pulmonary complications were observed in 17% of patients. Anastomotic leakage was observed in 8% of patients. Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. The 30-day mortality was 1%; 90-day mortality was 3%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. All patients had at least 7 months of follow-up with a median follow-up of 17 months. Median overall survival was not reached yet.!##!Conclusion!#!RAMIE with intrathoracic anastomosis (Ivor Lewis) for esophageal or gastro-esophageal junction cancer was technically feasible and safe. Postoperative complications and short-term oncologic results were comparable to the highest international standards nowadays

The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler

Background!#!For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures.!##!Methods!#!Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed.!##!Results!#!In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412).!##!Conclusion!#!There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy