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Use of indocyanine green for the reconstruction with Roux-en-Y after minimally invasive esophagectomy
Uso de verde de indocianina para la reconstrucción con Y-de-Roux posterior a esofagectomía mínimamente invasiva
Andrés Navarretea,b,
Corresponding author
andres_navarr38@hotmail.com

Corresponding author.
, Roberto Humeresa,b
a Departamento de Cirugía, Clínica Alemana, Santiago, Chile
b Departamento de Cirugía, Hospital Militar, Santiago, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Esophageal cancer is the seventh most common malignant neoplasm in the world<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Esophagectomy continues to be the mainstay of treatment for these patients&#46; During surgery&#44; restoring the continuity of the digestive tract is critical&#44; both in terms of risk of postoperative complications as well as subsequent quality of life&#46; The most common technique for reconstruction is the creation of a gastric tube&#46; The problem arises when the stomach is not available&#44; which can be due to the ingestion of caustic substances compromising the esophagus and stomach&#44; previous gastrectomy&#44; or gastric extension of a distal esophageal tumor&#46; In these cases&#44; the alternatives include the right or left colon and free jejunal interposition with vascular anastomosis&#46; Another less used alternative is Roux-en-Y reconstruction&#46; The use of the jejunum was first described by Roux in 1907<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; The jejunum is an ideal choice because of its size match with the esophagus&#44; the capacity for intrinsic peristalsis after reconstruction&#44; and the fewer anastomoses required&#46; The main drawback is the difficulty to mobilize the jejunum from the abdominal cavity to the mediastinum while maintaining optimal perfusion<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Indocyanine green &#40;ICG&#41; fluorescence is an emerging intraoperative method&#46; It enables us to evaluate the patient for and optimize lymphadenectomy&#44; while also evaluating tissue perfusion in order to avoid using tissues with poor perfusion&#44; thereby preventing postoperative ischemic complications<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a>&#46; Thus&#44; the use of indocyanine green could be a good tool when Roux-en-Y reconstruction is planned &#40;in which perfusion is essential&#41; by evaluating jejunal duct perfusion conditions throughout the surgery and avoiding the need to perform a vascular anastomosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 57-year-old man with a previous open total gastrectomy due to gastric cancer&#46; During follow-up&#44; a 2&#8201;cm lesion was found in the esophageal mucosa immediately above the esophagus-jejunal anastomosis&#44; and the biopsy confirmed adenocarcinoma&#46; The extension study was negative&#44; so we planned to perform surgical resection using a minimally invasive Ivor-Lewis type surgery with Roux-en-Y reconstruction&#46; The abdominal phase began with a laparoscopic approach&#44; releasing the adhesions from the previous surgery&#46; After restoration of the anatomy&#44; we performed complete dissection of the anterior esophageal-jejunal anastomosis together with the posterior dissection of the jejunum 10&#8201;cm below the anastomosis using a linear endostapler&#46; With the distal jejunum free&#44; we started to mobilize the mesentery&#44; evaluating the vascular distribution and jejunal perfusion using indocyanine green&#46; After identifying the jejunal arch by direct vision&#44; we began dissecting the vessels while avoiding injury to the main jejunal vascular supply in order to achieve better mobilization of the jejunum&#46; The final jejunal perfusion was evaluated to confirm optimal vascular supply before ending the abdominal phase &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The semiprone position was used for the thoracic phase&#46; Complete dissection of the esophagus was performed down to the area of the azygous vein&#46; The proximal margin was dissected with a harmonic scalpel&#46; The jejunal loop was mobilized to the area of &#8203;&#8203;the anastomosis to confirm that there was no tension in the tissues &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Another indocyanine green test was used to assess adequate perfusion when lifting the jejunum&#44; before performing the anastomosis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; An anastomosis was performed manually in two planes&#44; ensuring that it was tension-free&#44; and a nasogastric tube was placed before suturing the anterior side of the anastomosis&#46; The final Roux-en-Y evaluation was performed after completing the esophagojejunal anastomosis&#44; demonstrating adequate and optimal perfusion of the jejunal loop &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#44;D&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">During the postoperative period&#44; intake was initiated on day 3&#44; and the patient was discharged on day 7 without any postoperative complications&#46; The pathological study confirmed a moderately differentiated adenocarcinoma with negative proximal and distal margins&#59; the 13 lymph nodes were all negative&#46; A computed tomography scan and endoscopy were performed at 12 months of follow-up&#44; and no signs of tumor recurrence were found&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The use of Roux-en-Y for the posterior reconstruction of an esophagectomy has been previously described in the literature and is considered an alternative if the stomach is not available&#46; Despite this&#44; it is not frequently used due to the risk of jejunal loop ischemia and possible difficulty in mobilizing the jejunum through the chest&#46; This is the first case report using indocyanine green for the preparation and evaluation of the perfusion of the jejunal duct&#44; both in the abdominal and thoracic phases of the surgery&#46; ICG fluorescence is a new tool that makes this type of atypical reconstruction safer and&#44; therefore&#44; it may be considered an adequate and valuable technique in select cases&#46;</p></span>"
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Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos