Annals of Gastroenterological Surgery

Kalayarasan, Raja; Sai Krishna, Pothugunta

2024 Annals of Gastroenterological Surgery

doi: 10.1002/ags3.12862

Radical lymphadenectomy is the critical component of surgery for esophageal cancer. However, lymphadenectomy significantly contributes to postoperative morbidity, particularly in terms of pulmonary complications following esophagectomy. Function‐preserving mediastinal lymphadenectomy seeks to balance the procedure's necessary radicality and optimal functional outcomes. This approach emphasizes the preservation of the thoracic duct, tracheobronchial vascularity, and the pulmonary and recurrent laryngeal branches of the vagus nerve. Preservation of the thoracic duct is facilitated by indocyanine green fluorescence. Compared to the conventional technique of thoracic duct identification using anatomical landmarks, indocyanine green fluorescence lymphangiography offers real‐time feedback, making it particularly advantageous in cases with complex anatomy or when the thoracic duct is challenging to visualize using conventional methods. Preservation of pulmonary branches of the right vagus during subcarinal lymphadenectomy and left recurrent laryngeal nerve during left paratracheal node dissection are technically challenging. The description of two types of left recurrent laryngeal nerve node dissection and technical tips for nerve function preservation are outlined in this review. Intraoperative neuromonitoring is a useful adjunct for nerve‐sparing mediastinal lymphadenectomy. As ischemia to the respiratory tract impairs respiratory protective mechanisms, preservation of the tracheobronchial blood supply is critical. Preoperative imaging to detect bronchial artery anatomical variations and intraoperative assessment of perfusion using laser doppler flowmetry and indocyanine green fluorescence angiography are useful strategies to minimize tracheobronchial ischemia. Function‐preserving mediastinal lymphadenectomy has the potential to improve short‐ and long‐term outcomes after esophagectomy for esophageal cancer.

Cai, Lindi; Qiu, Guanglin; Zhu, Mengke; Han, Shangning; Zhao, Pengwei; Wang, Panxing; Li, Xiaowen; Liao, Xinhua; Che, Xiangming; Fan, Lin

2024 Annals of Gastroenterological Surgery

doi: 10.1002/ags3.12857

Shida, Dai; Ahiko, Yuka; Sakuyama, Naoki; Monma, Satoko; Kojima, Shigehiro

2024 Annals of Gastroenterological Surgery

doi: 10.1002/ags3.12861

In right‐sided colon cancer surgery, lymph node dissection around the superior mesenteric artery is necessary but technically challenging. Here we introduce the concept of “outermost layer‐oriented robotic surgery” to improve the safety, efficacy, and reproducibility of superior mesenteric artery nodal dissection. In this procedure, the thin, loose connective tissue layer between the autonomic nerve sheath of the superior mesenteric artery and adipose tissue bearing lymph nodes, termed “the outermost layer of the autonomic nerve,” is dissected. The procedure exposes the outermost layer of the nerve plexus covering the surface of the superior mesenteric artery with a width of approximately 1 cm, enabling direct visualization of the anatomy of the main arteries and, if they exist, jejunal veins which cross the superior mesenteric artery ventrally. This allows for sufficient dissection of main lymph nodes at the roots of the ileocolic artery, right colic artery, and middle colic artery and minimizes the risk of unforeseen bleeding. Thirty‐nine patients underwent robotic right hemicolectomy with this procedure. No intraoperative complications were observed. The median number of dissected lymph nodes was 50, including 16 main lymph nodes. The median operative time was 284 min, blood loss was 50 mL, and the median postoperative hospital stay was 8 days. Postoperative complications included two cases of Clavien–Dindo classification grade II, with no cases of grade III or higher. Chylous leakage as well as intractable diarrhea were not observed in any case. These findings demonstrate that the procedure can achieve safe and reliable lymph node clearance.

Kubota, Koji; Shimizu, Akira; Notake, Tsuyoshi; Nakamura, Satoshi; Soejima, Yuji

2024 Annals of Gastroenterological Surgery

doi: 10.1002/ags3.12858

Median arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap‐MALR) procedures are rare. In this study, we performed lap‐MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap‐MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato‐biliary‐pancreatic surgery, and one symptomatic case. In all cases, lap‐MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap‐MALR procedure in the treatment of MALS‐related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression.