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Fernández-Moreno MC, Barrios Carvajal ME, López Mozos F, Martí Obiol R, Guijarro Rozalén J, Casula E, Ortega J. Pilot Trial on Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer: Feasibility and Impact on Anastomotic Leakage (TIGOAL-I). ANNALS OF SURGERY OPEN 2024; 5:e379. [PMID: 38883947 PMCID: PMC11175858 DOI: 10.1097/as9.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/03/2024] [Indexed: 06/18/2024] Open
Abstract
Objective To evaluate the feasibility, safety, and effectiveness of gastric conditioning using preoperative arterial embolization (PAE) before McKeown esophagectomy at a tertiary university hospital. Background Cervical anastomotic leakage (AL) is a common complication of esophagectomy. Limited clinical evidence suggests that gastric conditioning mitigates this risk. Methods This pilot randomized clinical trial was conducted between April 2016 and October 2021 at a single-center tertiary hospital. Eligible patients with resectable malignant esophageal tumors, suitable for cervical esophagogastrostomy, were randomized into 2 groups: one receiving PAE and the other standard treatment. The primary endpoints were PAE-related complications and incidence of cervical AL. Results The study enrolled 40 eligible patients. PAE-related morbidity was 10%, with no Clavien-Dindo grade III complications. Cervical AL rates were similar between the groups (35% vs 25%, P = 0.49), even when conduit necrosis was included (35% vs 35%, P = 1). However, AL severity, including conduit necrosis, was higher in the control group according to the Clavien-Dindo ≥IIIb (5% vs 30%, P = 0.029) and Comprehensive Complication Index (20.9 vs 33.7, P = 0.01). No significant differences were found in other postoperative complications, such as pneumonia or postoperative mortality. Conclusions PAE is a feasible and safe method for gastric conditioning before McKeown minimally invasive esophagectomy and shows promise for preventing severe AL. However, further studies are required to confirm its efficacy.
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Affiliation(s)
- María-Carmen Fernández-Moreno
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - María Eugenia Barrios Carvajal
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - Fernando López Mozos
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - Roberto Martí Obiol
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | | | - Elisabetta Casula
- Department of Interventional Radiology. University Clinic Hospital of Valencia, Spain
| | - Joaquín Ortega
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
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A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial. Int J Surg 2022; 106:106921. [PMID: 36116675 DOI: 10.1016/j.ijsu.2022.106921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.
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Urbán D, Cserni T, Boros M, Juhász Á, Érces D, Varga G. Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies. Int Urol Nephrol 2021; 53:2221-2230. [PMID: 34435307 DOI: 10.1007/s11255-021-02971-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.
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Affiliation(s)
- Dániel Urbán
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Tamás Cserni
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of Paediatric Urology, The Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Mihály Boros
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Árpád Juhász
- Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Dániel Érces
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Gabriella Varga
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.
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Bonavina L. Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:907. [PMID: 34164541 PMCID: PMC8184442 DOI: 10.21037/atm.2020.03.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
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Barberio M, Felli E, Pop R, Pizzicannella M, Geny B, Lindner V, Baiocchini A, Jansen-Winkeln B, Moulla Y, Agnus V, Marescaux J, Gockel I, Diana M. A Novel Technique to Improve Anastomotic Perfusion Prior to Esophageal Surgery: Hybrid Ischemic Preconditioning of the Stomach. Preclinical Efficacy Proof in a Porcine Survival Model. Cancers (Basel) 2020; 12:cancers12102977. [PMID: 33066529 PMCID: PMC7602144 DOI: 10.3390/cancers12102977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Esophagectomy has a high rate of anastomotic complications thought to be caused by poor perfusion of the gastric graft, which is used to restore the continuity of the gastrointestinal tract. Ischemic gastric preconditioning (IGP), performed by partially destroying preoperatively the gastric vessels either by means of interventional radiology or surgically, might improve the gastric conduit perfusion. Both approaches have downsides. The timing, extent and mechanism of IGP remain unclear. A novel hybrid IGP method combining the advantages of the endovascular and surgical approach was introduced in this study. IGP improves unequivocally the mucosal and serosal blood-flow at the gastric conduit fundus by triggering new vessels formation. The proposed timing and extent of IGP were efficacious and might be easily applied to humans. This novel minimally invasive IGP technique might reduce the anastomotic leak rate of patients undergoing esophagectomy, thus improving their overall oncological outcome. Abstract Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (n = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA); (2) Min-IGP (n = 5): LGA-embolization, SGA-LapD; (3) Sham (n = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO2) by hyperspectral-imaging; (B) Serosal time-to-peak (TTP) by fluorescence-imaging; (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO2 and FCD-A index (41 ± 10.6%; 0.03 ± 0.03 respectively) than min-IGP (66.2 ± 10.2%, p-value = 0.004; 0.22 ± 0.02, p-value < 0.0001 respectively) and max-IGP (63.8 ± 9.4%, p-value = 0.006; 0.2 ± 0.02, p-value < 0.0001 respectively). Sham had higher LCL (9.6 ± 4.8 mL/mol) than min-IGP (4 ± 3.1, p-value = 0.04) and max-IGP (3.4 ± 1.5, p-value = 0.02). For StO2, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 ± 4.9 s) than max-IGP (10 ± 1.5 s, p-value = 0.0008) and min-IGP (14 ± 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.
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Affiliation(s)
- Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
- Correspondence:
| | - Eric Felli
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Margherita Pizzicannella
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Bernard Geny
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Veronique Lindner
- Department of Pathology, University Hospital of Strasbourg, 67000 Strasbourg, France;
| | - Andrea Baiocchini
- Department of Surgical Pathology, San Camillo Hospital, 00152 Rome, Italy;
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Michele Diana
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
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Michalinos A, Antoniou SA, Ntourakis D, Schizas D, Ekmektzoglou K, Angouridis A, Johnson EO. Gastric ischemic preconditioning may reduce the incidence and severity of anastomotic leakage after οesophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5830789. [PMID: 32372088 DOI: 10.1093/dote/doaa010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/17/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leakage after esophagectomy is a severe and life-threatening complication. Gastric ischemic preconditioning is a strategy for the improvement of anastomotic healing. Aim of this systematic review and meta-analysis is to investigate the impact of gastric ischemic preconditioning on postoperative morbidity. A systematic literature search was performed to identify studies comparing patients undergoing gastric ischemic preconditioning before esophagectomy with nonpreconditioned patients. Meta-analysis was conducted for the overall incidence of anastomotic leakage, severe anastomotic leakage, anastomotic stricture, postoperative morbidity, and mortality. Mantel-Haenszel odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed concerning preconditioning technique, the interval between preconditioning and surgery and the extent of preconditioning. Fifteen cohort studies were identified. Gastric preconditioning was associated with reduced overall incidence of anastomotic leakage (OR 0.73; 95% CI, 0.53-1.0; P = 0.050) and severe anastomotic leakage (OR 0.27; 95% CI, 0.14-0.50; P < 0.010), but not with anastomotic stricture (OR 1.18; 95% CI 0.38 to 3.66; P = 0.780), major postoperative morbidity (OR 1.03; 95% CI 0.45 to 2.36; P = 0.940) or mortality (OR 0.69; 95% CI 0.39 to 1,23; P = 0.210). Subgroup analyses did not identify any differences between embolization and ligation while increasing the interval between preconditioning and esophagectomy as well as the extent of preconditioning might be beneficial. Gastric ischemic preconditioning may be associated with a reduced incidence of overall and severe anastomotic leakage. Randomized studies are necessary to further evaluate its impact on leakage, refine the technique and define patient populations that will benefit the most.
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Affiliation(s)
| | - Stavros A Antoniou
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus.,Department of General Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Dimitrios Ntourakis
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Aris Angouridis
- Department of Internal Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Elizabeth O Johnson
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus
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Critical appraisal of gastric conduit ischaemic conditioning (GIC) prior to oesophagectomy: A systematic review and meta-analysis. Int J Surg 2020; 77:77-82. [PMID: 32198097 DOI: 10.1016/j.ijsu.2020.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Anastomotic leaks remain a major complication following oesophagectomy, accounting for high morbidity and mortality. Recently, gastric ischaemic conditioning (GIC) has been proposed to improve anastomotic integrity through neovascularisation of the gastric conduit. This systematic review and meta-analysis aim to determine the impact of GIC on postoperative outcomes following oesophagectomy. METHODS A systematic literature search was performed to identify studies reporting GIC for any indication of oesophageal resection up to April 25, 2019. The primary outcome was anastomotic leak. Secondary outcomes were conduit necrosis, anastomotic strictures, overall and major complications or in-hospital mortality. Meta-analyses were conducted using random-effects modelling. RESULTS Nineteen studies reported on GIC, of which 13 were comparative studies. GIC was performed through ligation in 13 studies and embolisation in six studies. GIC did not appear to reduce anastomotic leakages (OR 0.80, CI95: 0.51-1.24, p = 0.3), anastomotic strictures (OR 0.75, CI95: 0.35-1.60, p = 0.5), overall complications (OR 1.02, CI95: 0.48-2.16, p = 0.9), major complications (OR 1.06, CI95: 0.53-2.11, p = 0.9), or in-hospital mortality (OR 0.70, CI95: 0.32-1.53, p = 0.4). However, GIC was associated with reduced rates of conduit necrosis (OR 0.30, CI95: 0.11-0.77, p = 0.013). CONCLUSION GIC does not appear to reduce overall rates of anastomotic leakage after oesophagectomy but seems to reduce severity of leakages. More in depth studies are recommended.
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Schizas D, Michalinos A, Syllaios A, Dellaportas D, Kapetanakis EI, Hadjigeorgiou G, Vergadis C, Lasithiotakis K, Liakakos T. Staged esophagectomy: surgical legacy or a bailout option? Surg Today 2019; 50:1323-1331. [PMID: 31612330 DOI: 10.1007/s00595-019-01894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
Staged esophagectomy was developed in the mid-twentieth century in an attempt to reduce high rates of postoperative morbidity and mortality. Nowadays, the operation has almost been abandoned due to its significant disadvantages, especially the need for multiple surgeries, inability of patients to feed between operations, and morbidity of esophageal stoma. However, staged esophagectomy is still occasionally useful for very high-risk patients and in particular cases, for example multiple cancers of the aerodigestive tract and emergent esophagectomy. Staged esophagectomy is based on the division of surgical stress into two operations, which gives the patient time to recover before final restoration. Gastric tube ischemic preparation may be a more important mechanism in staged esophagectomy. This approach may survive and expand with the application of ischemic gastric pre-conditioning through embolization or laparoscopic ligation of the gastric arteries, which is a less explored and promising technique.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Adamantios Michalinos
- Department of Anatomy, European University of Cyprus, Diogenous 6 Str, CY-2404, Engomi, Nicosia, Cyprus.
| | - Athanasios Syllaios
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Dionysios Dellaportas
- Second Department of Surgery, National and Kapodistrian University of Athens, Aretaieion University Hospital, Vasillisis Sofias 76 str, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Rimini 1 Str. Chaidari, Athens, Greece
| | - Georgios Hadjigeorgiou
- Department of Anatomy, European University of Cyprus, Diogenous 6 Str, CY-2404, Engomi, Nicosia, Cyprus
| | - Chrysovalantis Vergadis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University Hospital of Heraklion, Panepistimiou 12 str, Heraklion, Greece
| | - Theodoros Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
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Minimally Invasive and Robotic Esophagectomy: A Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 13:391-403. [PMID: 30543576 DOI: 10.1097/imi.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
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Mingol-Navarro F, Ballester-Pla N, Jimenez-Rosellon R. Ischaemic conditioning of the stomach previous to esophageal surgery. J Thorac Dis 2019; 11:S663-S674. [PMID: 31080643 DOI: 10.21037/jtd.2019.01.43] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A gastric conduit is most frequently used for reconstruction in oesophageal surgery, and ischemia of the conduit is the most fragile aspect of the esophagogastric anastomosis with as consequence the anastomotic leakage. In order to avoid it, the concept of ischaemic conditioning of the stomach previous to surgery has been designed. The basis of ischemic conditioning is that interrupting vascularization of the stomach before making the anastomosis eases the gastric fundus adaptation to ischemic conditions. It consists of the interruption of the principal feeding arteries of the stomach (except the right gastroepiploic artery) weeks before esophagectomy. Previously published literature contemplates two different techniques: angiographic embolization or laparoscopic ligation or division of vessels. In this study, the anatomic and physio-pathologic background of ischemic preconditioning is described and the published current evidence is reviewed.
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Köhler H, Jansen-Winkeln B, Maktabi M, Barberio M, Takoh J, Holfert N, Moulla Y, Niebisch S, Diana M, Neumuth T, Rabe SM, Chalopin C, Melzer A, Gockel I. Evaluation of hyperspectral imaging (HSI) for the measurement of ischemic conditioning effects of the gastric conduit during esophagectomy. Surg Endosc 2019; 33:3775-3782. [DOI: 10.1007/s00464-019-06675-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 01/17/2019] [Indexed: 12/18/2022]
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12
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Neovascularization after ischemic conditioning of the stomach and the influence of follow-up neoadjuvant chemotherapy thereon. Wideochir Inne Tech Maloinwazyjne 2018; 13:299-305. [PMID: 30302142 PMCID: PMC6174163 DOI: 10.5114/wiitm.2018.75907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/26/2018] [Indexed: 01/22/2023] Open
Abstract
Introduction Esophagectomy and reconstruction remain the optimal treatment for patients with resectable esophageal cancer. Neovascularization after ischemic conditioning of the stomach before esophagectomy is a laparoscopic procedure which may potentially reduce gastric conduit ischemia. Aim To investigate the influence of ischemic conditioning on neovascularization along the greater curvature of the stomach and to explore the effect of neoadjuvant chemotherapy on neovascularization after ischemic conditioning. Material and methods Staging laparoscopy was performed before the main resection procedure; during this procedure ischemic conditioning was performed. Samples taken from the human stomach were divided into 3 groups: group A – patients after ischemic conditioning with a delay of 30–45 days after left gastric artery (LGA) ligation (n = 4); group B – patients who were undergoing neoadjuvant chemotherapy with a delay of 90–140 days after left gastric artery ligation (n = 4); and control group C – patients without ischemic conditioning (n = 7). Results After ischemic conditioning with a delay of 30–45 days, the count of neovessels along the greater curvature of the stomach increased from 5.4 ±0.7 in the control group to 17.5 ±0.9 in a low-power field of view (LPF) in group A and increased still further on average to 19.8 ±10.4 in group B. Conclusions Left gastric artery ligation only is a sufficient procedure for ischemic conditioning of the stomach. Neovascularization along the greater curvature is a continuous process that depends on delay time. Neoadjuvant therapy has no influence on the effect of neovascularization.
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Gastric Ischemic Conditioning Prior to Esophagectomy Is Associated with Decreased Stricture Rate and Overall Anastomotic Complications. J Gastrointest Surg 2018; 22:1501-1507. [PMID: 29845573 DOI: 10.1007/s11605-018-3817-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 05/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. METHODS We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. RESULTS Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). CONCLUSIONS Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.
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Miró M, Farran L, Estremiana F, Miquel J, Escalante E, Aranda H, Bettonica C, Galán M. Does gastric conditioning decrease the incidence of cervical oesophagogastric anastomotic leakage? Cir Esp 2018; 96:102-108. [PMID: 29459004 DOI: 10.1016/j.ciresp.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/12/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Oesophageal reconstruction by gastroplasty with cervical anastomosis has a higher incidence of dehiscence. The aim of the study is to analyse the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning of the gastric conduit. METHODS Prospective analysis of patients who underwent gastric conditioning two weeks prior to oesophageal reconstruction, from January 2001 to January 2014. The conditioning was performed by angiographic embolization of the left and right gastric artery, and splenic artery. The main variable analysed was the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis. Secondary variables analysed were the result of the conditioning, complications arising from that procedure and in the postoperative period, and mean length of postconditioning and postoperative hospital stay. RESULTS Gastric conditioning was indicated in 97 patients, with neoplasia being the most frequent aetiology motivating the oesophageal reconstruction (76%). 96 procedures were successfully carried out, arterial embolization was complete in 80 (83%). The morbidity rate was 13%, with no mortality. Postoperative morbidity was 45%; the most frequent complications associated with the surgery were respiratory problems. Six (7%) patients experienced cervical fistula, and all received conservative treatment. The rate of postoperative mortality was 7%. CONCLUSIONS In our serie the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning is 7%. Angiographic ischaemic conditioning is a procedure with acceptable morbidity.
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Affiliation(s)
- Mónica Miró
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - Leandre Farran
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Fernando Estremiana
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Jordi Miquel
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Elena Escalante
- Unidad de Angiorradiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Humberto Aranda
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Carla Bettonica
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Maica Galán
- Unidad de Tumores Esofágicos, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, España
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Heger P, Blank S, Diener MK, Ulrich A, Schmidt T, Büchler MW, Mihaljevic AL. Gastric Preconditioning in Advance of Esophageal Resection-Systematic Review and Meta-Analysis. J Gastrointest Surg 2017; 21:1523-1532. [PMID: 28439770 DOI: 10.1007/s11605-017-3416-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/27/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leakage is one of the most severe complications following esophageal resection. Among other strategies, gastric ischemic preconditioning has been proposed to improve anastomotic integrity. The aim of this systematic review is to investigate whether gastric preconditioning has influence on peri- or postoperative outcomes after esophageal resection. METHODS A systematic literature search was performed to identify studies comparing gastric preconditioning with non-preconditioned patients for any indication of esophageal resection. Random-effects meta-analyses were conducted for main outcomes. RESULTS Gastric preconditioning did not reduce anastomotic leakages (OR 0.76; 95%-CI 0.51 to 1.13; p = 0.18), anastomotic strictures (OR 1.10; 95%-CI 0.58 to 2.10; p = 0.76;), major complications (OR 1.14; 95%-CI 0.60 to 2.14; p = 0.69), or in-hospital mortality (OR 0.62; 95%-CI 0.28 to 1.40; p = 0.25). However, preconditioning reduced the rate of severe leaks requiring reoperation (OR 0.20; 95%-CI 0.08 to 0.53; p = 0.001). Increasing the period between preconditioning and esophageal resection over 2 weeks did not reduce anastomotic leakage compared to shorter waiting times (OR 0.65; 95%-CI 0.38 to 1.13; p = 0.13). CONCLUSION With current evidence, gastric preconditioning does not seem to reduce overall rates of anastomotic leakage after esophageal resection but seems to reduce severity of leakages.
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Affiliation(s)
- Patrick Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Susanne Blank
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Ischemic Conditioning of the Stomach in the Prevention of Esophagogastric Anastomotic Leakage After Esophagectomy. Ann Thorac Surg 2016; 101:1614-23. [PMID: 26857639 DOI: 10.1016/j.athoracsur.2015.10.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/07/2015] [Accepted: 10/12/2015] [Indexed: 12/11/2022]
Abstract
Esophagectomy with esophagogastric anastomosis is a major procedure, and its most feared complication is anastomotic leakage. Ischemic conditioning of the stomach is a method used with the aim of reducing the risk of leakage. It consists of partial gastric devascularization through embolization or laparoscopy followed by esophagectomy and anastomosis at a second stage, thus providing the time for the gastric conduit to adapt to the acute ischemia at the time of its formation. This review analyzes the information from all currently available experimental and clinical studies with the purpose of assessing the current role of the technique and to provide future recommendations.
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Eizaguirre E, Larburu S, Asensio JI, Rodriguez A, Elorza JL, Loyola F, Urdapilleta G, Navascués JME. Treatment of anastomotic leaks with metallic stent after esophagectomies. Dis Esophagus 2016; 29:86-92. [PMID: 25604136 DOI: 10.1111/dote.12298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The diagnosis and the treatment of anastomotic leak after esophagectomy are the keys to reduce the morbidity and mortality after this surgery. The stent plays an important role in the treatment of the leakage and in the prevention of reoperation. We have analyzed the database of the section of the esophagogastric surgery of Donostia University Hospital from June 2003 to May 2012. It is a retrospective study of 113 patients with esophagectomy resulting from tumor, and 24 (21.13%) of these patients developed anastomotic leak. Of these 24 patients, 13 (54.16%) have been treated with a metallic stent and 11 (45.84%) without a stent. The average age of the patients was 55.69 and 62.45 years, respectively. All patients treated with and without a stent have been males. Eight (61.5%) stents were placed in the neck and five (38.5%) in the chest. However, among the 11 fistulas treated without a stent, 9 patients had cervical anastomosis (81.81%) and 2 patients (18.18%) had anastomosis in the chest. Twelve patients (92.30%) with a stent preserve digestive continuity, and 10 patients (90.90%) were treated without a stent. One patient died in the stent group and one in the nonstent group. The treatment with metallic stent of the anastomotic leak after esophagectomy is an option that can prevent reoperation in these patients, but it does not decrease the average of the hospital stay. The stent may be more useful in thoracic anastomotic leaks.
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Affiliation(s)
- E Eizaguirre
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - S Larburu
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - J I Asensio
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - A Rodriguez
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - J L Elorza
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - F Loyola
- Department of Interventional Radiology, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - G Urdapilleta
- Department of Digestive Endoscopy, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
| | - J M E Navascués
- Department of Esophagogastric Surgery, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
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Hofstetter WL. The enigmatic esophageal anastomosis. J Thorac Dis 2015; 7:E344-6. [PMID: 26543627 DOI: 10.3978/j.issn.2072-1439.2015.09.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas, MD Anderson Cancer Center Houston, Texas, USA
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Abstract
MIE can provide patients with reduced morbidity and a rapid recovery in the treatment of benign conditions. There is few data examining the long-term outcomes of MIE specifically in the context of benign disease. At present, MIE should be performed in centers with experience in advanced minimally invasive esophageal surgery, and it requires a team approach. Multicenter, prospective randomized controlled trials will be required to determine the superiority of MIE compared with open esophagectomy. Further investigation will be required to determine the effect of MIE on quality of life and long-term outcomes in the treatment of benign conditions.
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Affiliation(s)
- Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, 320 E. North Avenue, Pittsburgh, PA 15212, USA.
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20
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Ney A, Kumar R. Does preoperative ischaemic conditioning with gastric vessel ligation reduce anastomotic leaks in oesophagectomy? Interact Cardiovasc Thorac Surg 2014; 19:121-4. [PMID: 24648469 DOI: 10.1093/icvts/ivu070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'does preoperative ischaemic conditioning with gastric vessel ligation prior to oesophagectomy reduce anastomotic leaks? Altogether more than 70 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Five papers represent level III evidence while the remainder two are considered level IV. None of the seven papers reports statistically significant P-values, although one non-randomized controlled cohort study approaches statistical significance at P = 0.07. Three of the level III papers suggest that preoperative ischaemic conditioning prior to oesophagectomy may be associated with a lower anastomotic leak severity; being managed endoscopically rather than with a surgical intervention, however, again, none reached statistical significance. Preoperative ischaemic conditioning prior to oesophagectomy may not be associated with an increase in blood loss or length of time at definitive operation, reported by one of the seven studies. One paper reports that the timing of preoperative ischaemic conditioning may be associated with a better anastomotic leak profile if carried out 2 weeks previously as opposed to 5 days ahead of definitive surgery, although not statistically significant. The most consistent method in the literature reported ligation or division of the left gastric artery reported in six of the seven papers. We, therefore, cannot conclude that preoperative ischaemic conditioning with gastric vessel ligation prior to oesophagectomy is associated with reduced anastomotic leaks.
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Affiliation(s)
- Alexander Ney
- Department of General Surgery and Digestive Diseases, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| | - Rohan Kumar
- Department of Minimal Access Surgery/Hepato-Pancreatico-Biliary Surgery, King's College Hospital, Denmark Hill, London, UK
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Markar SR, Arya S, Karthikesalingam A, Hanna GB. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol 2013; 20:4274-81. [PMID: 23943033 DOI: 10.1245/s10434-013-3189-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity. METHODS Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor. RESULTS No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005). CONCLUSIONS A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.
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Affiliation(s)
- Sheraz R Markar
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK,
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Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial. Surg Endosc 2012; 26:1822-9. [PMID: 22302533 DOI: 10.1007/s00464-011-2123-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 12/02/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Minimally invasive esophagectomy (MIE) is a viable alternative to open resection for the management of esophagogastric cancer. However, the technique may relate to a higher incidence of ischemia-related gastric conduit complications. Laparoscopic ischemic conditioning (LIC) by ligating the left gastric vessels 2 weeks before MIE may have a protective role, possibly through an improvement of conduit perfusion. This project was designed to evaluate whether LIC influenced ultimate conduit perfusion. METHODS A randomized controlled trial was designed to compare MIE with LIC (L) against MIE without (N). The project began in May 2009 and was offered to consecutive patients with the objective of recruiting 22 in each arm. Sample size calculations were based on data from previous clinical series. The main outcome measure was perfusion recorded by validated laser Doppler fluximetry, at the fundus (F) and greater curve (G); performed at routine staging laparoscopy and every stage of an MIE. A perfusion coefficient measured as ratio at stage of MIE over baseline was used for statistical analysis. RESULTS Sixteen patients were recruited before an interim analysis of the trial data. At staging laparoscopy perfusion at F was higher than at G (p = 0.016). In the L cohort, an apparent rise in perfusion at G is observed post intervention (p = 0.176). At MIE, baseline perfusion is comparable for both arms; however, a significant drop is observed at both locations once the stomach is mobilized and exteriorized (p = 0.001). Once delivered at the neck, perfusion coefficient is approximately 38% of baseline levels. However, there was no discernible difference between the L (38.3 ± 12) and N (37.7 ± 16.8) cohorts (p = 0.798). CONCLUSIONS LIC does not translate into an improved perfusion of the gastric conduit tip. The benefits reported from published clinical series suggest that the resistance of the conduit to ischemia occurs through alternative possibly microcellular mechanisms.
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Yuan Y, Duranceau A, Ferraro P, Martin J, Liberman M. Vascular conditioning of the stomach before esophageal reconstruction by gastric interposition. Dis Esophagus 2012; 25:740-9. [PMID: 22292613 DOI: 10.1111/j.1442-2050.2011.01311.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastric interposition with intrathoracic or cervical esophagogastrostomy is currently the preferred operation for reconstruction after esophagectomy. Anastomotic leaks however result from poor vascular supply to the proximal stomach. They are responsible for significant morbidity and mortality. 'Ischemic conditioning' of the interposed stomach has been proposed as a technique where the 'delay phenomenon' aims at improving the microcirculation of the gastric conduit and preventing anastomotic leakage. Experimental observations and clinical studies have been conducted to document the immediate effects and results of this approach. The aim of this work is to review the principles, pathophysiology, experimental, and clinical evidence related to vascular conditioning of the stomach prior to esophagectomy with gastric interposition and esophagogastric anastomosis. MEDLINE and PubMed were searched to identify articles related to vascular conditioning of the stomach. Cross references were added and reviewed to complete the reference list. The anatomic basis of ischemic conditioning, the prevalence of ischemic events on the gastric conduit, the methodology to assess the microcirculation before and after gastric devascularization, animal experiments, and clinical studies reported on this approach were reviewed. Ten experimental works, eleven clinical observations, four reviews, and two editorial commentaries addressing ischemic conditioning of the stomach were identified and reviewed. Experimental observations document improved microcirculation to the proximal stomach following partial gastric devascularization. Clinical reports show the feasibility and relative safety of gastric ischemic conditioning. Preliminary observations suggest potential improvements to the gastric microcirculation resulting from gastric ischemic conditioning. This approach may help prevent complications at the esophagogastric anastomosis. The actual level of evidence however cannot promote its use outside of clinical research protocols.
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Affiliation(s)
- Y Yuan
- Department of Surgery, Université de Montréal, Division of Thoracic Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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Minimally invasive esophagectomy with and without gastric ischemic conditioning. Surg Endosc 2011; 26:1637-41. [PMID: 22179469 DOI: 10.1007/s00464-011-2083-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 11/17/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Esophagectomy can be associated with significant morbidity such as leaks and strictures. Preoperative gastric ischemic conditioning is a concept aimed at inducing an ischemic insult to the gastric fundus and cardia prior to esophagectomy, thus leading to improvement of gastric perfusion. METHODS This retrospective study compared outcome data from 81 patients who underwent esophagectomy after laparoscopic gastric ischemic conditioning with that from 71 patients who underwent esophagectomy without conditioning. Gastric ischemic conditioning consisted of laparoscopic division of the left gastric vessels ± the short gastric vessels. The time interval from gastric ischemic conditioning to esophagectomy ranged from 2 to 75 days. Main outcome measures included demographics, mean time interval between staging and esophagectomy, and the rate of leaks and strictures following esophagectomy. RESULTS The two groups were comparable with respect to gender and age. In the gastric ischemic conditioning procedures, there were no conversions; the mean operative time was 57 ± 15 min, the mean length of hospital stay was 1.0 ± 1.1 days, and the rate of postoperative complications was 3.7%. The mean time interval between gastric ischemic conditioning and esophagectomy was 6.0 ± 5.4 days. There were no significant differences in the leak rate (11.1% for conditioning vs. 8.5% without conditioning) or stricture rate (29.6% for conditioning vs. 25.3% without conditioning) between the two groups. CONCLUSIONS Laparoscopic gastric ischemic conditioning is feasible and safe. However, the use of gastric ischemic conditioning in this study did not alter the clinical rate of postoperative leaks and strictures.
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Hoppo T, Jobe BA, Hunter JG. Minimally invasive esophagectomy: the evolution and technique of minimally invasive surgery for esophageal cancer. World J Surg 2011; 35:1454-63. [PMID: 21409606 DOI: 10.1007/s00268-011-1049-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Beginning with the widespread introduction of laparoscopic cholecystectomy in late 1989, minimally invasive surgical technique has been refined in conjunction with the development of advanced instrumentation and have subsequently been applied to increasingly complicated disease processes. Esophageal surgeons have increasingly incorporated minimally invasive surgery into their practice since the first laparoscopic fundoplication was described by Dallemagne et al. in 1991. Esophagectomy is associated with significant morbidity and mortality even in highly experienced centers. Many esophageal surgeons have had a great deal of interest in minimally invasive esophagectomy (MIE), which has the potential advantages of being a less traumatic procedure with a resultant improvement in postoperative convalescence and fewer wound and cardiopulmonary complications compared to the open approaches. Throughout the 1990s, as confidence with laparoscopic surgery of the esophagogastric junction grew, MIE was initially attempted with hybrid operations combining traditional open surgery with minimally invasive approaches. Subsequently, a totally laparoscopic transhiatal approach was described; however, this approach was perceived to be very challenging and has not gained widespread acceptance. Approaches used at present depend on cancer stage, cancer location, body habitus, and pulmonary function. For localized cancer (T1N0) or HGD, we prefer laparoscopic inversion esophagectomy (retrograde or antigrade). This approach may also be used for patients at high risk for thoracotomy. For locally advanced cancer in the middle third of the esophagus or for proximal third esophageal cancer, we prefer 3-field MIE (abdomen, and chest with neck anastomosis). For locally advanced cancer in the distal esophagus, especially in patients with a short thick neck, we prefer thoracoscopic-laparoscopic (2-field) esophagectomy (TLE).
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Affiliation(s)
- Toshitaka Hoppo
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Shadyside Medical Center, Suite 715, 5200 Centre Avenue, Pittsburgh, PA 15232, USA
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Wajed SA, Veeramootoo D, Shore AC. Video. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy. Surg Endosc 2011; 26:271-6. [PMID: 21858577 DOI: 10.1007/s00464-011-1855-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 07/18/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Total minimally invasive oesophagectomy (MIO) is a valid alternative to open surgery for the management of oesophagogastric cancer and may lead to a more rapid restoration of health-related quality of life post surgery. However, a high incidence of gastric conduit failure (GCF) has also been observed which could be detrimental to any potential benefits of this approach. Technical modifications have been introduced in an attempt to reduce conduit morbidity, and the aim of this study was to evaluate their efficacy. METHODS Minimally invasive oesophagectomy has been the procedure of choice in our unit since April 2004. Data on patient and surgical variables are entered onto a prospective database. Laparoscopic ischaemic conditioning (LIC) by ligation of the left gastric vessels 2 weeks prior to MIO was introduced in April 2006. Extracorporeal formation of the gastric conduit through a minilaparotomy was offered to patients since January 2008. Where present, GCF was characterised as one of three types: I, simple anastomotic leak; II, conduit tip necrosis; and III, whole conduit necrosis. RESULTS As of January 2010, 131 patients had undergone an MIO and GCF was observed in 21 patients (16.0%). Sixty-seven patients had LIC and 9 of them (13.4%) developed GCF (I, 10.4%; II, 0%; III, 3.0%) compared to 12 (18.8%) of 64 patients who did not have LIC (I, 6.3%; II, 7.8%; III, 4.7%). A total of 43 patients had an extracorporeally fashioned conduit and 6 (14.0%) developed GCF (I, 11.6%; II, 0%; III, 2.3%), whilst 88 had an intracorporeal conduit with 15 (17.0%) developing GCF (I, 6.8%; II, 5.7%; III, 4.5%). GCF can be reduced with the incorporation of LIC and an extracorporeally fashioned conduit, with possible elimination of type II conduit tip necrosis. CONCLUSIONS Surgical modification of a three-stage minimally invasive oesophagectomy technique, with the further incorporation of laparoscopic ischaemic conditioning and extracorporeal conduit formation, reduces gastric conduit morbidity, allowing the potential benefits of this approach to be realised.
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Affiliation(s)
- Shahjehan A Wajed
- Department of Upper Gastro-Intestinal Surgery, Exeter Oesophago-Gastric Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW, UK.
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Diana M, Hübner M, Vuilleumier H, Bize P, Denys A, Demartines N, Schäfer M. Redistribution of Gastric Blood Flow by Embolization of Gastric Arteries Before Esophagectomy. Ann Thorac Surg 2011; 91:1546-51. [DOI: 10.1016/j.athoracsur.2011.01.081] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 01/01/2023]
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Complicaciones de la anastomosis esofagogástrica en la operación de Ivor Lewis. Cir Esp 2011; 89:175-81. [DOI: 10.1016/j.ciresp.2010.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 10/18/2010] [Accepted: 10/19/2010] [Indexed: 11/23/2022]
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Experimental model of laparoscopic gastric ischemic preconditioning prior to transhiatal esophagectomy. Surg Endosc 2011; 25:2470-7. [DOI: 10.1007/s00464-010-1568-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
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Veeramootoo D, Shore AC, Shields B, Krishnadas R, Cooper M, Berrisford RG, Wajed SA. Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy. Surg Endosc 2009; 24:1126-31. [PMID: 19997936 DOI: 10.1007/s00464-009-0739-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 10/09/2009] [Indexed: 01/29/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIO) is now established as a valid alternative to open surgery for the management of esophagogastric cancers. However, a high incidence of ischemia-related gastric conduit failure (ICF) is observed, which is detrimental to any potential benefits of this approach. METHODS Since April 2004, MIO has been the procedure of choice for esophagogastric resection in the authors' unit. Data relating to the surgical technique were collected, with a focus on ischemic conditioning by laparoscopic ligation of the left gastric artery (LIC) 2 weeks or 5 days before resection. RESULTS A total of 97 patients underwent a planned MIO. Four in-patient deaths (4.1%) occurred, none of which were conduit related, and overall, 20 patients experienced ICF (20.6%). In four patients, ICF was recognized and dealt with at the initial surgery. The remaining 16 patients experienced this complication postoperatively, with 9 (9.3%) of them requiring further surgery. Of the 97 patients, 55 did not undergo ischemic conditioning, and conduit failure was observed in 11 (20%). Thirty-five patients had LIC at 2 weeks, and 2 (5.7%) experienced ICF. All seven patients (100%) who had LIC at 5 days experienced ICF. Timing of ischemic conditioning (p < 0.0001) had a definite impact on the conduit failure rate, and the benefit of ischemic conditioning at 2 weeks compared with no conditioning neared significance (p = 0.07). CONCLUSIONS Ischemic failure of the gastric conduit significantly impairs recovery after MIO. Ischemic conditioning 2 weeks before surgery may reduce this complication and allow the benefits of this approach to be realized.
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Affiliation(s)
- Darmarajah Veeramootoo
- Department of Thoracic and Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Royal Devon and Exeter Foundation Hospital, Exeter EX2 5DW, UK.
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Reavis KM. The esophageal anastomosis: how improving blood supply affects leak rate. J Gastrointest Surg 2009; 13:1558-60. [PMID: 19415398 PMCID: PMC2719724 DOI: 10.1007/s11605-009-0906-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 04/15/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Kevin M. Reavis
- Division of Gastrointestinal Surgery, Department of Surgery, University of California, Irvine Medical Center, 333 City Boulevard West, Suite 850, Orange, CA 92868 USA
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Ischemic preconditioning improves stability of intestinal anastomoses in rats. Int J Colorectal Dis 2009; 24:975-81. [PMID: 19381657 DOI: 10.1007/s00384-009-0696-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of our study was to establish whether ischemic preconditioning (IPC) directly before performing a small bowel anastomosis has an effect on anastomotic stability and healing. MATERIAL AND METHODS Forty male Wistar rats were randomized to five groups: control (CO, n = 8) with preparation of the superior mesenteric artery (SMA) but without IPC. IPC groups had different intervals of ischemia (occlusion of the SMA) and reperfusion: 10 min ischemia and 20 min reperfusion (IPC10/20, n = 7), 10 min ischemia and 30 min reperfusion (IPC10/30, n = 8), 15 min ischemia and 20 min reperfusion (IPC15/20, n = 8), and 15 min ischemia and 30 min reperfusion (IPC15/30, n = 9). On the fourth postoperative day, the animals were relaparotomized: bursting pressure, hydroxyproline concentration, and histological ischemia mucosal injury scale of the anastomosis were assessed. RESULTS Four days after operation, the mean bursting pressure was 73 +/- 6 mmHg in the control group, whereas it was significantly higher in IPC10/20 (113 +/- 11 mmHg; p = 0.018), IPC10/30 (110 +/- 13 mmHg; p = 0.001), and IPC15/30 (124 +/- 9 mmHg; p = 0.003). IPC15/20 did not show a significant difference (63 +/- 2 mmHg; p = 0.4). We did not find a significant effect regarding hydroxyproline concentration, but IPC diminished mucosal injury. CONCLUSIONS IPC directly before performing a small bowel anastomosis has a time-dependent beneficial effect on anastomotic stability, thus indicating a new clinical approach to improve the healing process of intestinal anastomosis.
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Oezcelik A, Banki F, DeMeester SR, Leers JM, Ayazi S, Abate E, Hagen JA, Lipham JC, DeMeester TR. Delayed esophagogastrostomy: a safe strategy for management of patients with ischemic gastric conduit at time of esophagectomy. J Am Coll Surg 2009; 208:1030-4. [PMID: 19476888 DOI: 10.1016/j.jamcollsurg.2009.02.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 01/05/2009] [Accepted: 02/04/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ischemia of the gastric conduit remains an important complication of esophagectomy and is associated with an increased risk of anastomotic leak and sepsis. We report a group of patients with multiple comorbid conditions and an ischemic gastric conduit that was successfully managed by a delayed esophagogastrostomy. STUDY DESIGN Between 2000 and 2007, esophagectomy with gastric pullup was performed in 554 patients. In 37 patients (7%), the combination of an ischemic graft and substantial comorbid conditions prompted delayed reconstruction to avoid an immediate esophagogastrostomy. In these patients, the gastric conduit was brought up and secured in the neck, and a cervical esophagostomy was constructed. Subsequently, a delayed esophagogastrostomy was performed through neck incision. Outcomes were analyzed at a median of 22 months (interquartile range [IQR], 13 to 30 months). RESULTS There were 29 male and 8 female patients, with a median age of 65 years (IQR, 58 to 75 years). Thirty-one patients had malignant disease; 12 received neoadjuvant therapy. All 37 patients recovered from their esophagectomy without evidence of ischemic necrosis or fistula from their gastric conduit. In 35 patients, a delayed esophagogastrostomy was performed at a median of 98 days (IQR, 89 to 110 days). At the time of reconstruction, all had well-perfused gastric conduits, and the anastomoses healed without leak, wound infection, or sepsis. A stricture developed in three patients and was treated with dilation. Delayed esophagogastrostomy was never performed in two patients because of development of recurrent malignant disease. CONCLUSIONS Delayed esophagogastrostomy is a safe strategy for management of patients with comorbidities and an ischemic gastric conduit at the time of esophagectomy.
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Affiliation(s)
- Arzu Oezcelik
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA
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Abstract
OBJECTIVES To review the outcomes of 104 consecutive minimally invasive esophagectomy (MIE) procedures for the treatment of benign and malignant esophageal disease. SUMMARY BACKGROUND DATA Although minimally invasive surgical approaches to esophagectomy have been reported since 1992, MIE is still considered investigational at most institutions. METHODS This prospective study evaluates 104 MIE procedures performed between August 1998 and September 2007. Main outcome measures include operative techniques, operative times, blood loss, length of stay, conversion rates, morbidities, and mortalities. RESULTS Indications for surgery were esophageal cancer (n = 80), Barrett esophagus with high-grade dysplasia (n = 6), recalcitrant stricture (n = 8), gastrointestinal stromal tumor (n = 3), and gastric cardia cancer (n = 7). Surgical approaches included thoracoscopic/laparoscopic esophagectomy with a cervical anastomosis (n = 47), minimally invasive Ivor Lewis esophagectomy (n = 51), laparoscopic hand-assisted blunt transhiatal esophagectomy (n = 5), and laparoscopic proximal gastrectomy (n = 1). There were 77 males. The mean age was 65 years. Three patients (2.9%) required conversion to a laparotomy. The median ICU and hospital stays were 2 and 8 days, respectively. Major complications occurred in 12.5% of patients and minor complications in 15.4% of patients. The incidence of leak was 9.6% and of anastomotic stricture was 26%. The 30-day mortality was 1.9% with an in-hospital mortality of 2.9%. The mean number of lymph nodes retrieved was 13.8. CONCLUSIONS Minimally invasive esophagectomy is feasible with a low conversion rate, acceptable morbidity, and low mortality. Our preferred operative approach is the laparoscopic\thoracoscopic Ivor Lewis resection, which provides a tension-free intrathoracic anastomosis.
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Mittermair C, Klaus A, Scheidl S, Maglione M, Hermann M, Margreiter R, Nguyen N, Weiss H. Functional capillary density in ischemic conditioning: implications for esophageal resection with the gastric conduit. Am J Surg 2008; 196:88-92. [PMID: 18367142 DOI: 10.1016/j.amjsurg.2007.07.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Revised: 07/12/2007] [Accepted: 07/12/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ischemia may lead to leakage at the esophagogastric anastomosis after esophagectomy. The aim of this study was to investigate time dependent changes of gastric microcirculation after ischemic conditioning. METHODS Twenty male Lewis rats were used and analyzed in 3 study groups and 1 control group. Group 1 (n = 5) underwent ligation of the left gastric artery and intravital fluorescence microscopy (IVM) on day 0; group 2 (n = 5) underwent IVM at 28 days after ligation of the LGA; and group 3 (n = 5) underwent IVM at 56 days after ligation of the LGA. The controls (n = 5) underwent sham surgery and IVM at 28 days thereafter. IVM was used to analyze gastric microcirculation by means of functional capillary density. RESULTS Ligation of the LGA immediately led to significant reduction of perfusion at the lesser (100.5 +/- 3.1 microm/mm(2) vs 220.4 +/- 7.4 microm/mm(2); P <.001) and greater curvatures (195.1 +/- 7.9 microm/mm(2) vs 234.1 +/- 9.4 microm/mm(2); P = .013). During 28 days, microcirculation at the lesser curve ameliorated (164.9 +/- 12.8 microm/mm(2)) and reached normal values after 56 days (215.8 +/- 7.4 microm/mm(2)). At the greater curve, microcirculation was improved during 4 (261.3 +/- 8 microm/mm(2)P = .039) and 8 weeks (317.9 +/- 10.3 microm/mm(2); P <.001 vs control). CONCLUSIONS Gastric microperfusion continuously improves after partial devascularization. The results support further clinical studies to optimize gastric ischemic conditioning in patients undergoing esophagectomy.
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Affiliation(s)
- Christof Mittermair
- Department of General and Transplant Surgery, Medical University Innsbruck, Innsbruck, Austria
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Cuenca-Abente F, Assalia A, del Genio G, Rogula T, Nocca D, Ueda K, Gagner M. Laparoscopic partial gastric transection and devascularization in order to enhance its flow. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2008; 2:3. [PMID: 18606017 PMCID: PMC2478649 DOI: 10.1186/1750-1164-2-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 07/07/2008] [Indexed: 12/12/2022]
Abstract
Background Esophagogastric fistula following an esophagectomy for cancer is very common. One of the most important factors that leads to its development is gastric isquemia. We hypothesize that laparoscopic gastric devascularization and partial transection is a safe operation that will enhance the vascular flow of the fundus of the stomach. Method Our study included eight pigs. Each animal had two operations. In the first one, a laparoscopic gastric devascularization and mobilization took place. Vascular flow was measured previous to the procedure and immediately after it with a laser doppler (endoscopic probe). After three weeks, a second operation took place. We re-measured the vascular flow and sent a sample of gastric fundus for histopathologic evaluation. Results The gastric fundus showed signs of neovascularization after both macroscopic and microscopic evaluation. These findings correlated with laser doppler measurements. Conclusion Laparoscopic gastric devascularization and partial transection is a safe procedure that increases the vascular flow of the stomach in a three week period. This finding can have a positive impact in terms of decreasing fistula formation.
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Affiliation(s)
- Federico Cuenca-Abente
- Division of Laparoscopic Surgery, Mount Sinai Minimally Invasive Surgery Center (MSMISC), Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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Varela E, Reavis KM, Hinojosa MW, Nguyen N. Laparoscopic Gastric Ischemic Conditioning Prior to Esophagogastrectomy: Technique and Review. Surg Innov 2008; 15:132-5. [DOI: 10.1177/1553350608317352] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Esophagectomy can be associated with significant peri-operative morbidity such as leaks and strictures. Gastric ischemia as a result of gastric devascularization is one of the several contributing factors that may play a role in development of these complications. In an attempt to improve gastric tissue perfusion, a technique of gastric ischemic conditioning was proposed. For patients with esophageal cancer and at the time of laparoscopic staging, partial gastric devascularization is achieved by division of the left gastric vessels. Esophagectomy is subsequently performed several days after the gastric ischemic conditioning procedure. Our experience showed that preoperative ligation of left gastric vessels prior to esophagogastrectomy is technically feasible and safe and may decrease ischemic complications such as leaks and strictures.
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Affiliation(s)
- Esteban Varela
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas,
| | - Kevin M. Reavis
- Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Marcelo W. Hinojosa
- Department of Surgery, University of California Irvine Medical Center, Irvine, California
| | - Ninh Nguyen
- Department of Surgery, University of California Irvine Medical Center, Irvine, California
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Lamas S, Azuara D, de Oca J, Sans M, Farran L, Alba E, Escalante E, Rafecas A. Time course of necrosis/apoptosis and neovascularization during experimental gastric conditioning. Dis Esophagus 2008; 21:370-6. [PMID: 18477261 DOI: 10.1111/j.1442-2050.2007.00772.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Apoptosis, necrosis and neovascularization are three processes that occur during ischemic preconditioning in a range of organs. In the stomach, the effect of this preconditioning (the delay phenomenon) has helped to improve gastric vascularization prior to esophagogastric anastomosis after esophagectomy. Here we present a sequential study of the histological recovery of the gastric fundus and the phenomena of apoptosis, necrosis and neovascularization in an experimental model of partial gastric ischemia. Partial gastric devascularization was performed by ligature of the left gastric vessels in Sprague-Dawley rats. Rats were assigned to groups in accordance with their evaluation period: control, 1, 3, 6, 10, 15 and 21 days. Histological analysis, caspase-3 activity, DNA fragmentation and vascular endothelial cell proliferation (Ki-67) were measured in tissue samples after sacrifice. After 24 h of partial gastric ischemia, rates of apoptosis and necrosis were higher in the experimental groups than in controls. Tissue injury was higher 3 and 6 days post-ischemia. From day 10 after partial gastric ischemia, apoptosis and necrosis started to decrease, and on days 15 and 21 showed no differences in relation to controls. Neovascularization began between days 1 and 3, reaching its peak at 15 days after ischemia and coinciding with complete histological recovery. Both necrosis and apoptosis play a role in tissue injury during the first days after partial gastric ischemia. After 15 days, the evolution of both the histology and the neovascularization suggested that this is the optimal time for performing gastric transposition.
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Affiliation(s)
- S Lamas
- Department of Surgery, Hospital Universitari de Bellvitge-Institut d'Investigació Biomédica de Bellvitge (IDIBELL), Barcelona, Spain
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Abstract
Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.
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40
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Nguyen NT, Longoria M, Sabio A, Chalifoux S, Lee J, Chang K, Wilson SE. Preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy. Ann Thorac Surg 2007; 81:2318-20. [PMID: 16731189 DOI: 10.1016/j.athoracsur.2005.05.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 04/29/2005] [Accepted: 05/10/2005] [Indexed: 01/08/2023]
Abstract
Anastomotic leak is a major cause for morbidity after esophagectomy. The cause is believed to be ischemia of the gastric conduit. Preoperative embolization of the left gastric vessels in preparation for esophagectomy has been shown to improve collateral blood flow of the gastric conduit and may reduce the frequency of anastomotic dehiscence after esophagectomy. This report describes the technique of laparoscopic division of the left gastric vessels in 9 patients who underwent pre-esophagectomy staging laparoscopy. Our initial experience demonstrates that laparoscopic ligation of the left gastric artery is a safe alternative to embolization and can be performed in conjunction with staging laparoscopy for patients with esophageal cancer.
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Affiliation(s)
- Ninh T Nguyen
- Department of Surgery and Medicine, University of California Irvine Medical Center, Orange, California, USA.
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41
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Pramesh CS, Mistry RC. Ischemic Preconditioning of the Gastric Conduit Prior to Esophageal Resection. Ann Thorac Surg 2007; 83:728. [PMID: 17258040 DOI: 10.1016/j.athoracsur.2006.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2006] [Revised: 07/02/2006] [Accepted: 09/05/2006] [Indexed: 11/30/2022]
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Enestvedt CK, Thompson SK, Chang EY, Jobe BA. Clinical review: Healing in gastrointestinal anastomoses, Part II. Microsurgery 2006; 26:137-43. [PMID: 16518802 DOI: 10.1002/micr.20198] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Complications arising from gastrointestinal anastomosis failures are a major source of morbidity and mortality. This review examines the effects of local blood flow on anastomotic healing, and discusses strategies for improving perfusion. Disruption of blood supply plays a significant role in the development of anastomotic leakage. Several methods have been suggested to improve perfusion. Omental pedicles have been employed as buttresses to promote angiogenesis, but efficacy in preventing anastomotic dehiscence has not been established. The administration of exogenous pharmacologic agents (such as vascular endothelial growth factor) is another potential strategy, although the oncological safety of this approach has been questioned. Two techniques which show promise in reducing anastomotic leakage rates include the vascular augmentation of grafts at risk for ischemia (supercharging) and ischemic conditioning (utilizing the delay phenomenon). Further studies of these strategies are needed to establish their efficacy and safety for routine use in gastrointestinal anastomoses.
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43
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Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic complications following esophagectomy. Semin Thorac Cardiovasc Surg 2004; 16:124-32. [PMID: 15197687 DOI: 10.1053/j.semtcvs.2004.03.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since the first reports of esophageal resection for the treatment of various esophageal diseases and disorders, morbidity related to the anastomosis and the chosen replacement conduit have remained a frequent nemesis, a constant concern, and an ongoing area of research and experimentation. In this review of this key component of esophageal resection, an analysis is presented of the most frequent complications related to the anastomosis and conduit: anastomotic leak, conduit necrosis, and conduit stricture. In each case, a review of the current pertinent literature and experience is reported with a view to providing management recommendations to minimize or prevent occurrences, to improve timely diagnosis and to best treat these complications when they arise.
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Affiliation(s)
- Stephen D Cassivi
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Ramos HE, Braga-Basaria M, Haquin C, Mesa CO, Noronha LD, Sandrini R, Carvalho GDA, Graf H. Preoperative embolization of thyroid arteries in a patient with large multinodular goiter and papillary carcinoma. Thyroid 2004; 14:967-70. [PMID: 15671777 DOI: 10.1089/thy.2004.14.967] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We herein report the case of a 51-year-old woman, who presented with a large goiter (250-300 g on palpation) with extension to the mediastinum and compression of the trachea causing dyspnea and with associated lumbar pain. Although two fine-needle aspiration biopsies of the gland were negative, a biopsy of a lesion in the spine shown on computed tomography (CT) scan was positive for metastatic papillary thyroid carcinoma. Because of the extent of the goiter and the potential of significant blood loss, total thyroidectomy was considered to be high risk. In an attempt to reduce the goiter size and try to minimize surgical risks, preoperative embolization with polyvinyl alcohol in an emulsion with histoacryl particles was performed 7 days before surgery under conventional angiography. This procedure allowed a significant reduction in blood perfusion to the gland, which resulted in a decrease on the size of the goiter facilitating surgical removal of the gland.
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Affiliation(s)
- Helton Estrela Ramos
- SEMPR, Serviço de Endocrinologia e Metabologia do Hospital das Clínicas da Universidade Federal do Paraná, Curitiba, Brazil.
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Kawai KI, Kakibuchi M, Sakagami M, Fujimoto J, Toyosaka A, Nakai K. Supercharged gastric tube pull-up procedure for total esophageal reconstruction. Ann Plast Surg 2001; 47:390-3. [PMID: 11601573 DOI: 10.1097/00000637-200110000-00005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Total esophageal reconstruction using a gastric tube is complicated because it sometimes causes postoperative complications such as anastomotic leakage, stenosis, or fistula formation resulting from insufficient blood flow at the distal end. To overcome this problem, during the past 5 years the authors performed seven additional microvascular anastomoses using the short gastric vessels of the gastric tube. No postoperative complications occurred except partial tracheal necrosis in 1 patient. Postoperative radiographic examination showed no reflux or stasis in all patients, and no evidence of necrosis at the anastomotic site of the pulled-up gastric tube was observed by postoperative endoscopy. This technique reduces risk and may contribute to the successful reconstruction of the digestive tract after total esophagectomy.
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Affiliation(s)
- K I Kawai
- Department of Otolaryngology, Hyogo College of Medicine, Japan
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46
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de Caro G, Cittadini G. Role of angiographic techniques in the preoperative staging and management of gastrointestinal neoplasms. SEMINARS IN SURGICAL ONCOLOGY 2001; 20:130-3. [PMID: 11398206 DOI: 10.1002/ssu.1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Gastrointestinal neoplasms are very common diseases, and their management does not usually require angiography for diagnostic and staging purposes. However, angiography may be required for further refinements in staging of vascular involvement or to obtain a detailed preoperative anatomy of the vessels. Finally, angiographic techniques may be useful for palliative or preoperative locoregional chemotherapy, and to treat hemorrhagic complications. This article reviews the capabilities and limits of angiographic techniques in the assessment and management of tumors of the alimentary tract.
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Affiliation(s)
- G de Caro
- Department of Experimental Medicine, Section of Diagnostic Imaging, S. Martino Hospital, University of Genoa, Italy.
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