P1.046. Pedicled Omental Flap Preserving the Right Gastroepiploic Artery for Gastric Conduit Reconstruction in Multistage Surgery for Aortoesophageal Fistula

Abstract

Abstract Topic Benign Disease: Other Background Aortoesophageal fistula is a rare but highly fatal condition. Thoracic endovascular aortic repair has led to improved early outcomes. However, subsequent aortic replacement, esophagectomy, and gastrointestinal reconstruction are required to achieve long-term survival. Conventional pedicled flaps using both gastroepiploic arteries can prevent gastric conduit reconstruction, requiring small or large intestinal substitutes associated with greater surgical invasiveness. Methods We developed the pedicled omental flap technique preserving the right gastroepiploic artery, which enabled simultaneous gastric conduit preparation and omental harvest in a multistage surgery. After a specific interval following esophagectomy, the omental flap was mobilized while preserving right gastroepiploic perfusion, and a gastric conduit was created (right gastroepiploic artery-preserving [RiGAP] method). Both were evaluated via indocyanine green imaging. The omental flap was delivered into the thoracic cavity for later graft coverage. Meanwhile, the gastric conduit was left in situ for delayed reconstruction. Results We experienced the seven cases of AEF treated with this method from 2022 to the present. Four presented with primary AEF and three with secondary AEF. Only one patient was female. If necessary, TEVAR was performed on the same day as the AEF diagnosis, and esophagectomy was also conducted immediately. The interval between esophagectomy, gastric conduit creation, pedicled omental flap harvesting using the RiGAP method, and aortic replacement was within 1 week. In a case, a gastric conduit was not created because subsequent total arch replacement was performed via median sternotomy. In another case, subsequent aortic re-replacement was not performed, and only thoracic cavity lavage, drainage, and omental coverage were performed. Thus, omental harvesting was performed laparoscopically. Although gastrointestinal reconstruction has not yet been performed in some cases, there have been no cases of anastomotic leakage or infection of the omental flap, and six patients are currently alive. Conclusion This method reduced invasiveness and facilitated staged treatment of aortoesophageal fistula with improved surgical flexibility.