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Pancreaticoduodenectomy is a radical treatment for pancreatic head cancer. However, it is sometimes difficult to perform pancreaticoduodenectomy, particularly in patients who have previously undergone esophagectomy with gastric conduit reconstruction. We herein describe a surgical technique for radical pancreaticoduodenectomy with microvascular reconstruction that preserves the gastric conduit. A 72-year-old male with a previous history of esophagectomy and gastric conduit reconstruction for esophageal cancer was referred to our hospital for surgical treatment of advanced pancreatic head cancer. After considering both the cancer curability and preservation of the gastric conduit, we performed a standard pancreaticoduodenectomy, and added a microvascular anastomosis of the gastroduodenal artery to the right gastroepiploic artery. In addition, we also performed reconstruction of the right gastroepiploic vein. This radical pancreaticoduodenectomy with microvascular reconstruction was safely and successfully performed, and it preserved the gastric conduit. The 6-month follow-up showed recurrence-free survival and a good quality of life.

A replaced common hepatic artery (RCHA) originating from the superior mesenteric artery (SMA) is a rare anomaly. We herein report such a case in a 62-year-old man who was scheduled to undergo a pancreatoduodenectomy for lower bile duct cancer. Computed tomography (CT) showed the RCHA to run along the ventral side of the pancreas. Abdominal angiography showed an RCHA originating from the SMA, which communicated with an aberrant left hepatic artery from the left gastric artery. No gastroduodenal artery was observed, but instead a direct ramification of a right gastroepiploic artery was seen. Similar cases from the English literature were reviewed. The RCHA was confirmed to course first along the ventral side of, and then within, the pancreas. Clamping of the RCHA did not influence the arterial flow in the liver, and the RCHA was subsequently divided without reconstruction. In three of the five reviewed cases in which the RCHA coursed either within or along the ventral side of the pancreas, no gastroduodenal artery was found, but instead a direct ramification of a right gastroepiploic artery was observed. A combination of CT and angiographic findings can help in both the diagnosis of an anomalous RCHA coursing either within or along the ventral side of the pancreas as well as in selecting optimal operative procedures. Pancreatoduodenectomy was performed with a curative resection according to our usual practice except for the fact that we preserved the aberrant left hepatic artery.

A 75-year-old woman presented with a pulsatile, movable mass, about 5 cm in diameter, in her lower abdomen. Abdominal ultrasonography revealed a circular mass with a variable hypo- and isoechoic border and a hypoechoic center. Color Doppler echography showed blood flow in the hypoechoic center, which was strongly enhanced on contrast-enhanced computed tomography. Based on these findings, we diagnosed a splanchnic artery aneurysm; however, celiac arteriography, performed twice, could not definitively identify it. An operation was performed under the tentative diagnosis of an aneurysm of the superior mesenteric artery or the gastroepiploic artery. On laparoscopic exploration, a globe-shaped mass, about 5 cm in diameter, was found in the right side of the greater omentum, which was diagnosed as an aneurysm of the right gastroepiploic artery. We resected the aneurysm laparoscopically and the patient had an uneventful postoperative course. Thus, laparoscopic surgery was effective for this patient who required no vascular reconstruction.

A laparoscopic cholecystectomy (LC) was successfully performed on a 61-year-old man who had undergone coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). He complained of right hypochondralgia 20 days after CABG. Gallstones were diagnosed and a cholecystectomy was performed 9 months after CABG. Under general anesthesia, the operation was performed using a pneumoperitonium. When a laparoscope was inserted, the RGEA pedicle could be clearly recognized. The pedicle obstructed the operating field and made the working space narrower than usual. No ST changes on the electrocardiogram were seen during LC, especially during the initiation of pneumoperitonium, the insertion of the ports, or when retracting the gallbladder. The postoperative course was uneventful. To avoid complications, care should be taken not to stretch the RGEA pedicle during LC, and careful monitoring of the electrocardiogram is also necessary. It is difficult to view the operating field and the RGEA pedicle together. It is therefore better to insert another laparoscope for concomitant monitoring of the RGEA pedicle.

We present herein two cases of a ruptured aneurysm of the visceral artery. The first case involved a 74-year-old man with abdominal pain who was admitted to our hospital with a tentative diagnosis of intra-abdominal bleeding of unknown origin. Computed tomography revealed a hematoma in the greater curvature of the stomach. At surgery, a hematoma along the right gastroepiploic artery was found and totally removed. Histological examination showed a pseudo-aneurysm of unknown etiology. The second case involved a 68-year-old man with progressive anemia who presented with spontaneous intra-abdominal bleeding. A ruptured aneurysm of the accessory middle colic artery was diagnosed by superior mesenteric angiography. The ruptured aneurysm was ligated and totally resected without a colectomy. Histological examination showed a pseudoaneurysm of unknown etiology. The postoperative courses were uneventful, and both patients were doing well at the time of writing.

A retrospective study was conducted to establish the criteria for performing a pylorus-preserving gastrectomy. This study was performed on 491 patients who had cancer of the middle-third stomach and had been curatively treated with a distal gastrectomy. The incidence of node metastasis for each lymph node station (the group of regional lymph nodes which have been anatomically defined and classified by the Japanese Classification of Gastric Carcinoma) was evaluated with reference to the depth of invasion, tumor size, and circumferential location, to show any significant correlations with an increase in tumor diameter or in the depth of tumor invasion. The benefits of resecting each station was then evaluated based on the incidence of metastasis to each station and the rate of long-term survivors among those with metastasis to each station. The benefit was substantial for the lymph nodes along the lesser curvature, along the right gastroepiploic artery, and at the base of the left gastric artery, while the advantages were almost negligible for the suprapyloric nodes and right paracardial nodes. In conclusion, carcinoma that fulfills either of the following conditions may thus be indicated to undergo a pylorus-preserving gastrectomy: (i) restricted to a depth of m or sml, (ii) a depth of sm2 or mp with a diameter of less than 2cm, (ii) a depth of sm2 or mp and located in the greater curvature.

Ischemic heart disorders are often treated by coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). We report the case of a 57-year-old man with a history of CABG using the RGEA, who underwent D2 radical total gastrectomy followed by Roux-en-Y anastomosis, with successful dissection of the #6 lymph nodes, while preserving the RGEA. The patient had a 9-month history of gastric cancer, during which time the Maruyama Vaccine (Specific Substance Maruyama, or SSM) was given as alternative therapy. This case report serves to demonstrate that radical gastrectomy can be safely performed after CABG using the RGEA, and that gastric cancer will progress in spite of SSM therapy.

Interruption of the right gastroepiploic artery (RGEA) used for prior coronary artery bypass grafting (CABG) may cause life-threatening myocardial ischemia during gastrectomy. This study investigated the cases treated in this department and pooled data in the literature to identify an adequate perioperative RGEA management strategy. Eight patients underwent gastrectomy after CABG with the RGEA. This study examined conditions, management of the RGEA, No. 6 lymph node metastasis, and complications of these cases and those in the pooled data. Percutaneous coronary intervention or a redo CABG was performed in advance in 7 and 1 patients, respectively. The RGEA was resected for dissection of No. 6 lymph nodes in 6 patients. Five patients had lymph node metastasis. Thirty-seven patients from 40 combined cases (92.5 %) underwent total or distal gastrectomy, but 17 patients (42.5 %) had RGEA resection. Resections of the RGEA and No. 6 lymph node metastasis were significantly higher in patients with perioperative coronary management than in those without such management. Coronary and celiac angiography and coronary revascularization are prerequisites to prevent cardiac events during gastrectomy and dissection of No. 6 lymph nodes should be performed with resection of RGEA. Standard lymph node dissection should therefore be performed with a curative intent for all patients even those undergoing gastrectomy after CABG using RGEA.

Cardiothoracic surgeons commonly use the internal thoracic artery (ITA) and the right gastroepiploic artery (RGEA) when performing a coronary artery bypass graft (CABG). Although the development of CABG surgery has enabled long-term survival in patients with coronary artery disease, malignant diseases are more common in older patients. We present the case of a 75-year-old man who had previously undergone CABG with the RGEA and had later developed advanced gastric cancer. We treated this patient with two courses of combination chemotherapy using S-1 and docetaxel as induction therapy, followed by successful tumor resection. Therefore, neoadjuvant chemotherapy was effective for preserving the CABG with the RGEA in a patient with advanced gastric cancer.

A 61-year-old man was found to have anemia 3 years after an aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) of the left intrathoracic artery to the left anterior descending artery and the right gastroepiploic artery (RGEA) to the right coronary artery (RCA) for aortic insufficiency and angina pectoris. A IIc gastric cancer in the antrum was subsequently diagnosed. Computed tomography (CT) and coronary angiography showed lymph node metastasis at the root of the RGEA, which perfused a large area of the inferoposterior wall of the heart. To prevent cardiac ischemia and perform complete #6 lymph node dissection, percutaneous intervention was carried out on the RCA before distal gastrectomy with D2 lymph node dissection, and the RGEA was reconstructed as a free graft to the left gastric artery. This procedure may be a surgical option for gastric cancer in patients who have undergone CABG using the RGEA.

A 66-year-old woman with aortic stenosis underwent an aortic root replacement with a composite graft and coronary artery reconstruction 2 years before presentation. On coronary angiography performed 2 years after operation, saphenous vein graft (SVG) to right coronary artery and SVG to first diagonal branch had both become totally occluded. SVG to left anterior descending artery showed 75% stenosis on the heel side of the distal anastomosis. The patient underwent a second coronary artery bypass via a left thoracotomy (the left internal thoracic artery was anastomosed to the first diagonal branch by interposing it with the left radial artery) and a small laparotomy (the right gastroepiploic artery was anastomosed to the right coronary artery) without a cardiopulmonary bypass. This approach is preferable to avoiding both a resternotomy and cardiopulmonary bypass in patients requiring repeat surgery.

We report a case of severe mediastinitis infected by methicillin-resistant Staphylococcus aureus (MRSA) after a coronary arterial bypass using the internal thoracic arteries and the right gastroepiploic artery (RGEA) in which mediastinitis was treated by an omental transfer. The patient was a 60-year-old man diagnosed as having an acute myocardial infarction of the left anterior wall. There was severe coronary stenosis of three vessels involving the left main trunk. The patient underwent a coronary arterial bypass with four grafts using the internal thoracic arteries, the RGEA, and the saphenous vein. Postoperative heart failure led to wound infection, resulting in mediastinitis infected by MRSA. Debridement and immediate closure with omental drainage was successfully performed without irrigation. After the establishment of the RGEA graft, the omentum is still viable and usable for mediastinal drainage.