Rakesh Krishnadas

Laparoscopic ischaemic conditioning of the stomach may reduce gastric-conduit morbidity following total minimally invasive oesophagectomy

OBJECTIVE Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. METHODS This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. RESULTS Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p=0.211 and p=0.176 Fishers exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. CONCLUSION In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.

Transgastric drainage of the oesophagus: managing difficult oesophageal injuries.

We describe a technique for maintaining patency of the injured or repaired oesophagus while providing vacuum drainage of the oesophageal lumen. A small midline laparotomy is performed. A lubricated 36F soft chest drain (pull-through end) is introduced into the oesophagus using a percutaneous endoscopic gastrostomy (PEG) set, and pulled out through the stomach wall. The drain is brought out through the abdominal wall and the stomach is anchored to the peritoneum. The transgastric drain is positioned across the oesophageal defect. A feeding jejunostomy is placed. Decontamination and drainage of the chest is performed if the patients condition allows. The patient takes sterile water by mouth to maintain drain patency, with -10 cm H(2)O suction applied. We have used this drainage procedure in seven patients (Boerhaaves syndrome (n=4), operative injury (n=3)). In five patients with injuries close to the oesophagogastric junction, this method was used as an adjunct to primary repair. There were no deaths; the oesophageal defect healed in all patients without stricture. All patients are swallowing normally at follow-up. This procedure is presented as an option for patients who are unfit for primary repair, or whose primary repair would benefit from efficient drainage and protection.

Video-Assisted Approach Combined with the Open Brompton Technique for Intracavitary Drainage of Giant Bullae

The modified Monaldi procedure represents a nonexcisional treatment option for patients with giant bullous emphysema as an alternative to bullectomy. We want to highlight its role in the surgical treatment of emphysema and discuss changes made to the open-access Brompton approach through introduction of video-assisted thoracic surgical technique.

Accelerated Treatment for Post-Lobectomy Empyema: New Indication for an Established Procedure

A 68-year-old male underwent a right upper lobectomy for non-small cell lung cancer (NSCLC) complicated by a delayed-onset empyema. The infected pleural space was successfully cleansed,applying the principles of accelerated treatment first described by the Weder group for patients sustaining an empyema after pneumonectomy. This strategy has been proved to be safe and effective even in cases of pleural space infection after minor lung resections, and we therefore recommend it for consideration as an additional treatment option for this patient group alongside the established techniques.

Pulmonary sequestration with unusually large feeding vessel.

www.elsevier.com/locate/ejcts Images in cardio-thoracic surgery Pulmonary sequestration with unusually large feeding vessel Tom Waterfall , Rakesh Krishnadas , Alexander Spiers , Richard Berrisford a,* Department of Thoracic Surgery, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom Department of Radiology, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom