World Journal of Surgery

, Volume 38, Issue 1, pp 138–143 | Cite as

Hemodynamics of the Reconstructed Gastric Tube During Esophagectomy: Assessment of Outcomes with Indocyanine Green Fluorescence

  • Youichi Kumagai
  • Toru Ishiguro
  • Norihiro Haga
  • Koki Kuwabara
  • Tatsuyuki Kawano
  • Hideyuki Ishida



Construction of a gastric tube that is well perfused with blood during esophagectomy is the most important factor in avoiding anastomotic leakage. We clarified the hemodynamics of the reconstructed gastric tube with indocyanine green (ICG) fluorescence.


In 20 patients undergoing gastric tube reconstruction during esophagectomy, we evaluated blood flow in the gastric tube with ICG fluorescence imaging. We divided the patients into two groups according to the quality of blood flow to the gastric tube—“good” (n = 9) and “sparse or absent” (n = 11)—based on visual assessment of the anastomosis of the right and left gastroepiploic vessels. We measured the time from initial enhancement of the root of the right gastroepiploic artery until enhancement of the most cranial branch of the left gastroepiploic artery and tip of the gastric tube.


The gastric tube was divisible into three zones according to the dominant arteries present in the greater curvature under ICG fluorescence. The left gastroepiploic artery was enhanced in a direction opposite that of physiological blood flow in all cases. The median period from initial enhancement of the root of the right gastroepiploic artery to the most cranial branch of the left gastroepiploic artery until perfusion up to the tip of the gastric tube did not differ significantly between the “good” and the “sparse or absent” groups (P = 0.24, 0.68)


It is essential to preserve the whole vessel arcade of the greater curvature to achieve good blood perfusion in the gastric tube. The ICG fluorescence method has potential usefulness for evaluation of blood flow in the gastric tube.


Anastomotic Leakage Gastric Tube Gastric Wall Short Gastric Vessel Gastroepiploic Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported by a grant from Saitama Medical Center, Saitama Medical University.

Conflict of interest

The authors declare no conflicts of interest.


  1. 1.
    Wormuth JK, Heitmiller RF (2006) Esophageal conduit necrosis. Thorac Surg Clin 16:11–22PubMedCrossRefGoogle Scholar
  2. 2.
    Ando N, Ozawa S, Kitagawa Y et al (2000) Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years. Ann Surg 232:225–232PubMedCrossRefGoogle Scholar
  3. 3.
    Orringer MB, Marshall B, Iannettony MD (1999) Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 230:392–400PubMedCrossRefGoogle Scholar
  4. 4.
    Peracchia A, Bardini R, Ruol A et al (1988) Esophageal anastomotic leak. A prospective study of predisposing factors. J Thorac Cardiovasc Surg 95:685–691PubMedGoogle Scholar
  5. 5.
    Briel JW, Tamhankar AP, Hagen JA et al (2004) Prevalence and risk factors for ischemia, leak and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 198:536–542PubMedCrossRefGoogle Scholar
  6. 6.
    Moorehead RJ, Wong J (1990) Gangrene in esophageal substitute after resection and bypass procedures for carcinoma of the esophagus. Hepatogastroenterology 37:364–367PubMedGoogle Scholar
  7. 7.
    Akiyama H, Miyazono H, Tsurumaru M et al (1978) Use of the stomach as an esophageal substitute. Ann Surg 188:606–610PubMedCrossRefGoogle Scholar
  8. 8.
    Miyazaki T, Kuwano H, Kato H et al (2002) Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy. World J Surg 26:1319–1323. doi: 10.1007/s00268-002-6366-9 PubMedCrossRefGoogle Scholar
  9. 9.
    Schilling MK, Mettler D, Redaelli C et al (1997) Circulatory and anatomic differences among experimental gastric tubes as esophageal replacement. World J Surg 21:992–997. doi: 10.1007/s002689900338 PubMedCrossRefGoogle Scholar
  10. 10.
    Tsekov C, Belyaev O, Tcholakov O et al (2006) Intraoperative Doppler assessment of gastric tube perfusion in esophagogastroplasty. J Surg Res 132:98–103PubMedCrossRefGoogle Scholar
  11. 11.
    Ikeda Y, Niimi M, Kan S et al (2001) Clinical significance of tissue blood flow during esophagectomy by laser Doppler flowmetry. J Thorac Cardiovasc Surg 122:1101–1106PubMedCrossRefGoogle Scholar
  12. 12.
    Awano T, Sakatani K, Yokose N et al (2010) Intraoperative EC-IC bypass blood flow assessment with indocyanine green angiography in moyamoya and non-moyamoya ischemic stroke. World Neurosurg 73:668–674PubMedCrossRefGoogle Scholar
  13. 13.
    Kang Y, Lee J, Kwon K et al (2010) Dynamic fluorescence imaging of indocyanine green for reliable and sensitive diagnosis of peripheral vascular insufficiency. Microvasc Res 80:552–555PubMedCrossRefGoogle Scholar
  14. 14.
    Yamamoto M, Sasaguri S, Sato T (2011) Assessing intraoperative blood flow in cardiovascular surgery. Surg Today 41:1467–1474PubMedCrossRefGoogle Scholar
  15. 15.
    Unno N, Suzuki M, Yamamoto N et al (2008) Indocyanine green fluorescence angiography for intraoperative assessment of blood flow: a feasibility study. Eur J Vasc Endovasc Surg 35(2):205–207PubMedCrossRefGoogle Scholar
  16. 16.
    Giunta RE, Holzbach T, Taskov C et al (2005) Prediction of flap necrosis with laser induced indocyanine green fluorescence in a rat model. Br J Plast Surg 58:695–701PubMedCrossRefGoogle Scholar
  17. 17.
    Kamp MA, Slotty P, Turowski B et al (2012) Microscopic-integrated quantitative analysis of intraoperative indocyanine green fluorescence angiography for blood flow assessment: first experience in 30 patients. Neurosurgery 70:65–74PubMedCrossRefGoogle Scholar
  18. 18.
    Holm C, Mayr E, Höfter E et al (2002) Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg 55:635–644PubMedCrossRefGoogle Scholar
  19. 19.
    Saito T, Yano M, Motoori M et al (2012) Subtotal gastrectomy for gastric tube cancer after esophagectomy: a safe procedure preserving the proximal part of gastric tube based on intraoperative ICG blood flow evaluation. J Surg Oncol 106:107–110PubMedCrossRefGoogle Scholar
  20. 20.
    Shimada Y, Okamura T, Nagata T et al (2011) Usefulness of blood supply visualization by indocyanine green fluorescence for reconstruction during esophagectomy. Esophagus 8:259–266PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Ishiguro T, Kumagai Y, Ono T et al (2012) Usefulness of indocyanine green angiography for evaluation of blood supply in a reconstructed gastric tube during esophagectomy. Int Surg 97:340–344PubMedCrossRefGoogle Scholar
  22. 22.
    Matsuda T, Kaneda K, Takamatsu M et al (2010) Reliable preparation of the gastric tube for cervical esophagogastrostomy after esophagectomy for esophageal cancer. Am J Surg 199:61–64CrossRefGoogle Scholar
  23. 23.
    Kono K, Sugai H, Omata H et al (2007) Transient bloodletting of the short gastric vein in the reconstructed gastric tube improves gastric microcirculation during esophagectomy. World J Surg 31:780–784. doi: 10.1016/j.surg.2009 PubMedCrossRefGoogle Scholar
  24. 24.
    Murakami M, Sugiyama A, Ikegami T et al (1999) Additional microvascular anastomosis in reconstruction after total esophagectomy for cervical esophageal carcinoma. Am J Surg 178:263–266PubMedCrossRefGoogle Scholar
  25. 25.
    Yoshimi F, Asato Y, Ikeda S et al (2006) Using the supercharge technique to additionally revascularize the gastric tube after subtotal esophagectomy for esophageal cancer. Am J Surg 191:284–287PubMedCrossRefGoogle Scholar
  26. 26.
    Sekido M, Yamamoto Y, Minakawa H et al (2003) Use of the “supercharge” technique in esophageal and pharyngeal reconstruction to augment microvascular blood flow. Surgery 134:420–424PubMedCrossRefGoogle Scholar
  27. 27.
    Fujisawa Y, Nakamura Y, Kawachi Y et al (2012) Indocyanine green fluorescence-navigated sentinel node biopsy showed higher sensitivity than the radioisotope or blue dye method, which may help to reduce false-negative cases in skin cancer. J Surg Oncol 106:41–45PubMedCrossRefGoogle Scholar
  28. 28.
    Aoyama K, Kamio T, Ohchi T et al (2011) Sentinel lymph node biopsy for breast cancer patients using fluorescence navigation with indocyanine green. World J Surg Oncol 9:157PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Youichi Kumagai
    • 1
  • Toru Ishiguro
    • 1
  • Norihiro Haga
    • 1
  • Koki Kuwabara
    • 1
  • Tatsuyuki Kawano
    • 2
  • Hideyuki Ishida
    • 1
  1. 1.Department of Digestive Tract and General Surgery, Saitama Medical CenterSaitama Medical UniversityKawagoeJapan
  2. 2.Department of SurgeryTokyo Medical and Dental UniversityTokyoJapan

Personalised recommendations