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Ann Thorac Surg 1995;60:382-385
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Laparotomy After Using the Gastroepiploic Artery Graft: Retrogastric Versus Antegastric Route

Departments of Cardiovascular Surgery and General Surgery, Geisinger Medical Center, Danville, Pennsylvania, and Department of Surgery, The Williamsport Hospital, Williamsport, Pennsylvania

Accepted for publication March 9, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
Background. Most cardiac surgeons prefer the antegastric route for the right gastroepiploic artery (RGEA) graft. When placed anterior to the stomach, the RGEA pedicle may adhere to the greater omentum, or to the anterior abdominal wall, and may be injured during future abdominal operations.

Methods. To avoid this potentially lethal complication, we prefer to place the RGEA graft behind the stomach and the left lobe of the liver. In our experience with 144 patients in whom the retrogastric route was used, 7 patients required an abdominal operation (2 had cholecystectomy, 2 had a partial colectomy, 1 had repair of paraesophageal hernia, and 2 had repair of abdominal wall complications). There was no need to dissect the RGEA graft in any of these patients.

Results. There was no evidence of myocardial ischemia or other complications during or after the operation in any patient.

Conclusions. Based on our experience and the fact that any injury to the RGEA graft may have catastrophic consequences, we strongly advocate the retrogastric route to minimize the risk of injury to the RGEA graft during a subsequent laparotomy.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
See also page 386.

Since the right gastroepiploic artery (RGEA) was introduced as an alternative conduit for coronary revascularization [1, 2], very few authors have addressed the problem of potential injury to the graft during future abdominal operations [3, 4]. Even a relatively simple procedure, such as a cholecystectomy, may result in a high risk and complicated operation if the RGEA graft had been placed anterior to the stomach, and may become a formidable challenge to the general surgeon [5].

See also page 458.

Most cardiac surgeons [2–10] employ the antegastric route because it allows easier identification of any bleeding sites from the RGEA pedicle. However, a major disadvantage to this approach is that the RGEA may adhere to the greater omentum, or to the anterior abdominal wall, and it may be impossible to distinguish the RGEA pedicle from the surrounding fatty tissues (Fig 1).

View larger version (65K): [in this window] [in a new window]   Fig 1. . Cross-section of the upper abdomen, showing the right gastroepiploic artery graft in close proximity with the anterior abdominal wall when the antegastric route is used; however, the right gastroepiploic artery is well protected behind the stomach when the retrogastric route is used. (a = artery; AO = aorta; IVC = inferior vena cava; LT = left; RT = right; R-GEA = right gastroepiploic artery; v = vein.)

We prefer to use the retrogastric route for several reasons: first, when the RGEA graft is placed behind the stomach, the length of the RGEA is shorter, which usually correlates with better flows and a larger lumen for the anastomosis; second, the risk of kinking at the anastomosis is greater if the RGEA is placed anterior to the stomach; third, the RGEA graft is more likely to be stretched by gastric dilatation if positioned anterior to the stomach; and, fourth, because the RGEA graft is less likely to be injured during a future laparotomy if placed behind the stomach and the left lobe of the liver because it cannot adhere to the anterior abdominal wall or to the greater omentum and because dissection of the RGEA pedicle from the surrounding structures usually is not necessary for most abdominal operations.

The purpose of this article is to report 7 patients, in whom the RGEA graft had been placed posterior to the stomach, who underwent an uneventful abdominal operation. We also intend to caution other cardiac surgeons against the liberal use of the antegastric route for the RGEA graft.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
Between November 1992 and December 1994, the RGEA was used as a pedicled graft for coronary revascularization in 144 patients. Their ages ranged from 34 to 82 years (mean age, 63.9 years). Our technique for RGEA harvesting has been described in detail in a separate publication [11]. We routinely divide all the omental branches and the short gastric branches between silk ligatures to assure proper hemostasis. We do not use the electrocautery, and we do not rely on hemostatic clips or automatic stapling devices. Our major emphasis is on placing the RGEA graft posterior to the stomach and the left lobe of the liver, as suggested by Pym [1], Perrault [12], and their associates.

Our experience with 7 patients who subsequently underwent an abdominal operation is summarized. In 3 of these patients (patients 1, 2, and 3), the use of the RGEA resulted in complications that later required a laparotomy. In 4 other patients (patients 4, 5, 6, and 7), an unrelated surgical problem also required an abdominal operation.

Patient 1
A 61-year-old man with postinfarction angina underwent coronary artery bypass grafting to three vessels and endarterectomy of the anterior descending coronary artery in February 1993. The posterior descending coronary artery was grafted with a pedicled RGEA graft. His postoperative electrocardiogram showed a septal infarct, but his recovery was otherwise uneventful. At follow-up, he was asymptomatic except for a large incisional hernia in his upper abdominal incision. An elective repair was performed in April 1994, using Marlex mesh. The RGEA graft was well protected behind the stomach, and it was not necessary to dissect it from the anterior abdominal wall. There were no electrocardiographic changes, and the cardiac enzyme levels remained normal.

Patient 2
A 61-year-old man with multiple risk factors, including diabetes, severe obesity, and chronic obstructive pulmonary disease, was admitted in March 1993 with unstable angina. He underwent coronary artery bypass grafting to four vessels, including an in-situ RGEA graft. He was discharged after 7 days, following an uneventful recovery. Ten days later he noticed serous drainage from the laparotomy incision. Examination revealed a dehiscence of the lower sternum and the abdominal wound. The entire sternum was rewired, and the laparotomy was closed with heavy retention sutures. An epigastric fascial defect recurred and was repaired with a right rectus abdominis muscle flap. The wound healed properly after this last procedure. The RGEA graft was not visualized or disturbed during any of these procedures.

Patient 3
A 67-year-old woman who underwent coronary revascularization in March 1994, including a pedicled RGEA graft to the posterior descending coronary artery, experienced severe left subcostal pain, nausea and vomiting after each meal, approximately 3 months after her operation. A barium study of the upper gastrointestinal tract showed a herniation of her gastric fundus, which appeared above the left diaphragm (Fig 2). The paraesophageal hernia was repaired in July 1994. The RGEA pedicle was identified easily, and no traction was applied to it while the gastric fundus was reduced back into the abdominal cavity. Her postoperative recovery was uneventful, with no electrocardiographic signs of ischemia and no enzyme elevation. Her symptoms were relieved completely.

View larger version (274K): [in this window] [in a new window]   Fig 2. . Upper gastrointestinal barium study demonstrating a herniation of the gastric fundus through the diaphragmatic opening (arrow) created for the right gastroepiploic artery graft: (A) frontal view, (B) lateral view.

Patient 5
A 79-year-old man had severe systemic hypertension, renal insufficiency, bilateral claudication, and gangrene of some toes. He was diagnosed to have severe aortoiliac occlusive disease, bilateral renal artery stenosis, and moderate to severe carotid artery disease. Before proceeding with major vascular procedures, we performed coronary angiography because of a markedly abnormal echocardiogram. In May 1994, coronary revascularization was performed using the RGEA graft. The ascending aorta was not clamped because it was heavily calcified. All the distal anastomoses were done with a beating heart, as described in a separate publication [13]. During his postoperative recovery, his left lower extremity became more ischemic, requiring an amputation. Three weeks later, he appeared septic and complained of severe diffuse abdominal pain. Abdominal ultrasound showed a distended gallbladder. An emergency cholecystectomy and common bile duct exploration were done. The RGEA pedicle was neither visualized nor dissected during the operation, and excessive traction in the area of the pylorus was avoided. There were no electrocardiographic changes during or after the operation, and cardiac enzyme levels remained normal. At follow-up, 12 months later, the patient was free of symptoms.

Patient 6
A 62-year-old woman with history of diabetes and previous stripping of bilateral varicose veins was admitted in December 1993 with unstable angina. Coronary angiography revealed critical left main coronary stenosis. She underwent urgent coronary revascularization with four arterial conduits, including an RGEA graft to the right coronary artery. She had no postoperative complications and had no recurrence of her angina. Ten months later she was hospitalized with a diagnosis of acute cholecystitis. Using a right subcostal incision, a cholecystectomy was performed. The RGEA graft was neither visualized nor dissected during the operation. The electrocardiogram and serum enzyme levels remained normal, and her postoperative recovery was uneventful.

Patient 7
An 81-year-old man who underwent coronary artery bypass grafting in August 1994 had recurrent angina. Repeat coronary angiography revealed an occluded saphenous vein graft to the right coronary artery, with a fresh clot within the graft. Reoperation was performed in September 1994, using an RGEA graft to replace the occluded vein graft. He has had no angina since his second operation. A rectal carcinoma was diagnosed after an episode of rectal bleeding, and an abdominal-perineal resection was performed in February 1995. The RGEA graft was left undisturbed. There were no regional or distant metastases. His postoperative course was uneventful except for a brief episode of sinus bradycardia on the third postoperative day. His electrocardiogram and cardiac enzyme levels, however, remained normal.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
The RGEA is an excellent conduit for coronary revascularization and, when used as a pedicled graft, has a patency rate similar to the internal mammary artery graft [4, 8–10]. Even at advanced age, both arteries have a very low prevalence of atherosclerosis [6, 14].

Use of the RGEA does not reduce the gastric mucosal blood flow, is not associated with increased surgical risk [15], and usually does not prolong hospital stay [12]. However, it involves entering the abdominal cavity, it makes the operative procedure more complex, and its long-term implications are yet unknown, because it may complicate future abdominal operations [3, 8, 16].

Very few abdominal complications secondary to the use of the RGEA have been reported, such as postoperative bleeding [4, 8, 12], pancreatitis [16], and incisional hernias [4]. In our series, 2 patients (1.4%) had abdominal wound complications, including an early dehiscence and an incisional hernia late after operation. To prevent these wound complications, we now use retention sutures routinely.

We observed a herniation of the gastric fundus through the diaphragmatic opening for the RGEA graft in 1 patient (patient 3) (see Fig 2). It was probably caused by creation of the hole in the diaphragm more posteriorly than usual. This complication may be prevented by creating the opening for the RGEA graft in the fibrous portion of the diaphragm.

Although the prevalence of intraabdominal complications after using the RGEA graft is relatively low, a major concern is the risk of injuring the RGEA during future abdominal operations [3, 4, 16]. For this reason, it may be advantageous to place the RGEA behind the stomach [7].

There is no consensus on which route to use for the RGEA graft, and very few articles address the issue of potential problems with a future abdominal operation [3, 4, 7]. Suma and associates [15] advocate the antegastric route because they find it easier to verify hemostasis in the RGEA pedicle. However, bleeding is usually not a problem if the branches of the RGEA were divided carefully between silk ligatures, as recommended by Mills and associates [6]. We do not rely on hemostatic clips, because they can come off easily during manipulation of the graft [6]. The electrocautery is not recommended either, because it may cause serious intimal damage to the RGEA, similar to the observations by Lehtola and colleagues [17] on the internal mammary artery. A case of gastric perforation secondary to excessive use of the electrocautery also has been reported [18].

To avoid the risk of injury to the RGEA graft, Suma and co-workers [9] recommend combined coronary revascularization with the RGEA and cholecystectomy in patients with silent gallstones. However, any patient may need a laparotomy later in life for other reasons.

Verkkala and associates [7] do not advocate using the RGEA graft in patients with a history of abdominal illnesses that may eventually require an operation. Another option they suggest is to reanastomose the proximal end of the RGEA to the aorta, using it as a ``free'' graft. In our opinion, these are poor alternatives, because the patency rate of ``free'' RGEA grafts is considerably lower [9]. We believe that, even if a laparotomy is planned (for example, in patient 4, who underwent a right hemicolectomy), it is safe to use the RGEA as a pedicled graft as long as it is placed behind the stomach to protect it.

In summary, if the RGEA graft is positioned anterior to the stomach, it may adhere to the greater omentum or to the anterior abdominal wall. Under such circumstances, the pedicle of the RGEA graft may be difficult to distinguish from the surrounding fatty tissues and may be more prone to injury during future abdominal operations. Therefore, we strongly recommend the routine use of the retrogastric route to minimize the risk of injury during a subsequent laparotomy.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
We are very grateful to Lisa Peñalver, BA, medical illustrator, for providing the artistic illustration, and to Sheldon D. Henry, MD, and Joseph R. Calder, Jr, MD, for providing follow-up information on their patients.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 
Address reprint requests to Dr Dietl, Department of Cardiovascular Surgery, Geisinger Medical Center, Danville, PA 17822-1343.

	References

Top Footnotes Abstract Introduction Patients and Methods Comment Acknowledgments References

 

1. Pym J, Brown PM, Charrette EJP, Parker JO, West RO. Gastroepiploic–coronary anastomosis: a viable alternative bypass graft. J Thorac Cardiovasc Surg 1987;94:256–9.[Abstract]
2. Carter MJ. The use of the right gastro-epiploic artery in coronary artery bypass grafting. Aust N Z J Surg 1987;57: 317–21.[Medline]
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4. Grandjean JG, Boonstra PW, den Heyer P, Ebels T. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309–16.[Abstract/Free Full Text]
5. Terada Y, Suma H. Cholecystectomy after coronary artery bypass grafting using right gastroepiploic artery [Letter]. Ann Thorac Surg 1994;57:1370.
6. Mills NL, Hockmuth DR, Everson CT, Robart CC. Right gastroepiploic artery used for coronary artery bypass grafting: evaluation of flow characteristics and size. J Thorac Cardiovasc Surg 1993;106:579–86.[Abstract]
7. Verkkala K, Jarvinen A, Keto P, Virtanen K, Lehtola A, Pellinen T. Right gastroepiploic artery as a coronary bypass graft. Ann Thorac Surg 1989;47:716–9.[Abstract]
8. Lytle BW, Cosgrove DM, Ratliff NB, Loop FD. Coronary artery bypass grafting with the right gastroepiploic artery. J Thorac Cardiovasc Surg 1989;97:826–31.[Abstract]
9. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Takayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615–23.[Abstract]
10. Isomura T, Hisatomi K, Hirano A, Hayashida N, Ohishi K. Use of the right gastroepiploic artery as a pedicled arterial graft for coronary revascularization. Eur J Cardiothorac Surg 1993;7:38–41.[Abstract]
11. Dietl CA, Pharr WF, Berkheimer MD, et al. Which is the graft of choice for the right coronary artery system? Comparison between the right internal mammary artery and the right gastroepiploic artery. Circulation (in press).
12. Perrault LP, Carrier M, Hebert Y, et al. Clinical experience with the right gastroepiploic artery in coronary artery bypass grafting. Ann Thorac Surg 1993;56:1082–4.[Abstract]
13. Dietl CA, Madigan NP, Laubach CA, et al. Myocardial revascularization using the ``no-touch'' technique, with mild systemic hypothermia, in patients with a calcified ascending aorta. J Cardiovasc Surg 1995;36:39–44.[Medline]
14. Suma H, Takanashi R. Arteriosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 1990;50:413–6.[Abstract]
15. Suma H, Wanibuchi Y, Furuta S, Takeuchi A. Does use of gastroepiploic artery graft increase surgical risk? J Thorac Cardiovasc Surg 1991;101:121–5.[Abstract]
16. Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:706–11.[Abstract]
17. Lehtola A, Verkkala K, Jarvinen A. Is electrocautery safe for internal mammary artery (IMA) mobilization? A study using scanning electron microscopy (SEM). Thorac Cardiovasc Surg 1989;37:55–7.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Charles A. Dietl Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dietl, C. A. Articles by Pagana, T. J. Search for Related Content PubMed PubMed Citation Articles by Dietl, C. A. Articles by Pagana, T. J. Related Collections Related Articles