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Aiolfi A, Bona D, Bonitta G, Bonavina L. Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis. Ann Surg 2024; 279:410-418. [PMID: 37830253 DOI: 10.1097/sla.0000000000006124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
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Aiolfi A, Bona D, Bonitta G, Bonavina L. Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis. Updates Surg 2023; 75:1633-1643. [PMID: 37498484 DOI: 10.1007/s13304-023-01601-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
Ischemia at the anastomotic site is thought to be a protagonist in the development of anastomosis-related complications while different strategies to overcome this problem have been reported. Gastric ischemic conditioning (GIC) prior to esophagectomy has been described with this intent. Evaluate the effect of GIC on anastomotic complications after esophagectomy. Scopus, Web of Science, MEDLINE, and PubMed were investigated up to March 31st, 2023. We considered articles that appraised short-term outcomes after GIC vs. no GIC in patients undergoing esophagectomy. Anastomotic leak (AL), anastomotic stricture (AS), and gastric conduit necrosis (GCN) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Fourteen studies (1760 patients) were included. Of those, 732 (41.6%) underwent GIC, while 1028 (58.4%) underwent one-step esophagectomy. Compared with no GIC, GIC was related to a reduced RR for AL (R RR = 0.63; 95% CI 0.47-0.86; p < 0.01) and AS (RR = 0.51; 95% CI 0.29-0.91; p = 0.02), whereas no differences were found for GCN (RR = 0.56; 95% CI 0.19-1.61; p = 0.28). Postoperative pneumonia (RR = 1.09; p = 0.99), overall complications (RR = 0.87; p = 0.19), operative time (SMD - 0.58; p = 0.07), hospital stay (SMD 0.66; p = 0.09), and 30-day mortality (RR = 0.69; p = 0.22) were comparable. GIC prior to esophagectomy seems associated with a reduced risk for AL and AS. Further studies are necessary to identify the subset of patients who can benefit from this procedure, the optimal technique, and the timing of GIC prior to esophagectomy.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Luigi Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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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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Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak. Wideochir Inne Tech Maloinwazyjne 2021; 16:669-677. [PMID: 34950261 PMCID: PMC8669984 DOI: 10.5114/wiitm.2021.105529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Morbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy. Aim To quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD). Material and methods We identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days. Results Eleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation. Conclusions Laparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.
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Jogiat UM, Sun WYL, Dang JT, Mocanu V, Kung JY, Karmali S, Turner SR, Switzer NJ. Gastric ischemic conditioning prior to esophagectomy reduces anastomotic leaks and strictures: a systematic review and meta-analysis. Surg Endosc 2021; 36:5398-5407. [PMID: 34782962 DOI: 10.1007/s00464-021-08866-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gastric ischemic conditioning (GIC) is a strategy to promote neovascularization of the gastric conduit to reduce the risk of anastomotic complications following esophagectomy. Despite a number of studies and reviews published on the concept of ischemic conditioning, there remains no clear consensus regarding its utility. We performed an updated systematic review and meta-analysis to determine the impact of GIC, particularly on anastomotic leaks, conduit ischemia, and strictures. METHODS A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was performed on February 5th, 2020 by a university librarian after selection of key search terms with the research team. Inclusion criteria included human participants undergoing esophagectomy with gastric conduit reconstruction, age ≥ 18, N ≥ 5, and GIC performed prior to esophagectomy. Our primary outcome of interest was anastomotic leaks. Our secondary outcome was gastric conduit ischemia, anastomotic strictures, and overall survival. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel fixed-effects model. RESULTS A total of 1712 preliminary studies were identified and 23 studies included for final review. GIC was performed in 1178 (53.5%) patients. Meta-analysis revealed reduced odds of anastomotic leaks (OR 0.67; 95% CI 0.46-0.97; I2 = 5%; p = 0.03) and anastomotic strictures (OR 0.48; 95% CI 0.29-0.80; I2 = 65%; p = 0.005). Meta-analysis revealed no difference in odds of conduit ischemia (OR 0.40; 95% CI 0.13-1.23; I2 = 0%; p = 0.11) and no difference in odds of overall survival (OR 0.54; 95% CI 0.29-1.02; I2 = 22%; p = 0.06). CONCLUSION GIC is associated with reduced odds of anastomotic leaks and anastomotic strictures and may decrease morbidity in patients undergoing esophagectomy. Further prospective randomized trials are needed to better identify the optimal patient population, timing, and techniques used to best achieve GIC.
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Affiliation(s)
- Uzair M Jogiat
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Warren Y L Sun
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Jerry T Dang
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Valentin Mocanu
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Shahzeer Karmali
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Simon R Turner
- Division of Thoracic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Noah J Switzer
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada.
- Division of General Surgery, Department of Surgery, Royal Alexandra Hospital, Room 415 Community Services Center, 10240 Kingsway Avenue, Edmonton, AB, T5H3V9, Canada.
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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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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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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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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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Findlay L, Yao C, Bennett DH, Byrom R, Davies N. Non-inferiority of minimally invasive oesophagectomy: an 8-year retrospective case series. Surg Endosc 2017; 31:3681-3689. [PMID: 28078465 DOI: 10.1007/s00464-016-5406-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/21/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The trend towards laparoscopic surgery seen in other specialties has not occurred at the same pace in oesophagectomy. This stems from concerns regarding compromised oncological clearance, and complications associated with gastric tube necrosis and anastomotic failure. We present our experience of minimally invasive oesophagectomy (MIO) compared to open and hybrid surgery. We aim to ascertain non-inferiority of MIO by evaluating impact on survival, oncological clearance by resection margin and lymph node harvest and post-operative complications. METHODS Data were sourced retrospectively 2008-2015. Three approaches were studied. MIO (3-stage Mckeown), hybrid (2-stage Ivor Lewis, laparoscopy, thoracotomy) and open (2-stage Ivor Lewis). RESULTS Five-year survival was 54.2%. Surgical approach had no significant impact on survival at any stage of disease (Stage 0/I p = 0.98; stage II p = 0.2; stage III p = 0.76). There was no statistically significant difference in oncological clearance by resection margins between procedures when compared by disease stage (p = 0.49). A higher number of nodes were harvested in hybrid [median 27.5 (6-65)] and open surgeries [median 26 (4-54)] than in MIO [median 20 (7-44)] (p > 0.01). Numbers of nodes resected did not impact risk of recurrence [recurrence, median 25 (6-54), no recurrence, 26 (4-65)] (p = 0.25). Anastomotic strictures (22.4%) and potential leaks (17.9%) were more common in MIO (strictures p > 0.01, leaks p = 0.08), although associated morbidity was lower. Respiratory complications were less common in MIO (2.9%) versus hybrid (13.3%) (p = 0.02). Wound infection and chyle leak were also lower (wound 1.5% MIO 3.5% open, p = 0.6; chyle leak 1.5% MIO, 6.7% hybrid, p = 0.2). CONCLUSIONS Our results show no negative impact of MIO on survival or oncological clearance. Respiratory and wound complications are lower in MIO, but rates of anastomotic strictures and potential anastomotic leaks are increased. This may be due to the longer length of conduit and subclinical ischaemia at the anastomosis and merits further evaluation.
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Affiliation(s)
- L Findlay
- Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK. .,Department of General Surgery, Salisbury District Hospital, Odstock Road, Salisbury, SP2 8BJ, UK.
| | - C Yao
- Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK
| | - D H Bennett
- Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK
| | - R Byrom
- Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK
| | - N Davies
- Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK
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Ghelfi J, Brichon PY, Frandon J, Boussat B, Bricault I, Ferretti G, Guigard S, Sengel C. Ischemic Gastric Conditioning by Preoperative Arterial Embolization Before Oncologic Esophagectomy: A Single-Center Experience. Cardiovasc Intervent Radiol 2017; 40:712-720. [PMID: 28050659 DOI: 10.1007/s00270-016-1556-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/22/2016] [Indexed: 01/25/2023]
Abstract
PURPOSE Surgical esophagectomy is the gold standard treatment of early-stage esophageal cancer. The procedure is complicated with significant morbidity; the most severe complication being the anastomotic leakage. Anastomotic fistulas are reported in 5-25% of cases and are mainly due to gastric transplant ischemia. Here, we report our experience of ischemic pre-conditioning using preoperative arterial embolization (PreopAE) before esophagectomy. MATERIALS AND METHODS The medical records of all patients who underwent oncologic esophagectomy from 2008 to 2015 were retrospectively reviewed. Patients were divided into two groups: patients who received PreopAE, and a control group of patients who did not benefit from ischemic pre-conditioning. The target arteries selected for PreopAE were the splenic artery, left gastric artery, and right gastric artery. Evaluation of the results was based on anastomotic leakage, postoperative mortality, technical success of PreopAE, and complications related to the embolization procedure. RESULTS Forty-six patients underwent oncologic esophagectomy with PreopAE and 13 patients did not receive ischemic conditioning before surgery. Thirty-eight PreopAE were successfully performed (83%), but right gastric artery embolization failed for 8 patients. Anastomotic leakage occurred in 6 PreopAE patients (13%) and in 6 patients (46%) in the control group (p = 0.02). The mortality rate was 2% in the PreopAE group and 23% in the control group (p = 0.03). Eighteen patients suffered from partial splenic infarction after PreopAE, all treated conservatively. CONCLUSION Preoperative ischemic conditioning by arterial embolization before oncologic esophagectomy seems to be effective in preventing anastomotic leakage.
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Affiliation(s)
- Julien Ghelfi
- Clinique Universitaire de Radiologie et Imagerie Médicale, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France.
| | - Pierre-Yves Brichon
- Clinique Universitaire de Chirurgie Thoracique, Vasculaire et Endocrinienne, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
| | - Julien Frandon
- Clinique Universitaire de Radiologie et Imagerie Médicale, CHU de Nîmes, 30029, Nîmes Cedex 09, France
| | - Bastien Boussat
- Département d'Information Médicale, Pôle de Santé Publique, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
| | - Ivan Bricault
- Clinique Universitaire de Radiologie et Imagerie Médicale, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
| | - Gilbert Ferretti
- Clinique Universitaire de Radiologie et Imagerie Médicale, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
| | - Sébastien Guigard
- Clinique Universitaire de Chirurgie Thoracique, Vasculaire et Endocrinienne, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
| | - Christian Sengel
- Clinique Universitaire de Radiologie et Imagerie Médicale, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 09, France
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16
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Vascular anatomy of the stomach related to resection procedures strategy. Surg Radiol Anat 2016; 39:433-440. [DOI: 10.1007/s00276-016-1746-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
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17
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Strosberg DS, Merritt RE, Perry KA. Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy. Surg Endosc 2016; 31:1371-1375. [DOI: 10.1007/s00464-016-5122-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022]
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18
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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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19
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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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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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Yetasook AK, Leung D, Howington JA, Talamonti MS, Zhao J, Carbray JM, Ujiki MB. Laparoscopic ischemic conditioning of the stomach prior to esophagectomy. Dis Esophagus 2013; 26:479-86. [PMID: 22816598 DOI: 10.1111/j.1442-2050.2012.01374.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.
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Affiliation(s)
- A K Yetasook
- Minimally Invasive Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL 60201, USA
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23
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Levy RM, Pennathur A, Luketich JD. Randomized trial comparing minimally invasive esophagectomy and open esophagectomy: early perioperative outcomes appear improved with a minimally invasive approach. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200069 DOI: 10.1053/j.semtcvs.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Esophagectomy is an important curative treatment modality for esophageal cancer, but is a complex operation with associated risks. A minimally invasive approach to esophagectomy may decrease the risks associated with resection. Recently, an important study was published in the Lancet by Biere and colleagues that reported the results of a randomized study, with the primary endpoint of postoperative pulmonary infection, comparing minimally invasive esophagectomy versus open esophagectomy for esophageal cancer. The findings from this trial confirm the data from previous, non-randomized studies and highlight the substantial early postoperative benefits of minimally invasive esophagectomy.
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Affiliation(s)
- Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania 15213, USA
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Abstract
BACKGROUND This study evaluated the safety and efficacy of endoscopy in diagnosing anastomotic leaks after esophagectomy. METHODS One hundred consecutive postesophagectomy patients, all having reconstruction using the stomach, underwent endoscopy in the first week after operation. The anastomosis and gastric mucosa were examined for evidence of ischemia, necrosis, and leak. RESULTS There was no evidence that the procedure caused damage to the anastomosis or gastric conduit. The results of 79 examinations were normal, 15 showed gastric ischemia, 2 showed a leak, and 4 showed ischemia plus leakage. The 15 patients with ischemia alone were monitored with a repeat endoscopy after a further week: a late leak developed in 1 patient that was diagnosed at the second examination. No further leaks developed subsequently, making endoscopy 100% accurate in the diagnosis of leaks after esophagectomy. CONCLUSIONS Esophagoscopy within 1 week of esophagectomy is a safe and highly accurate method of diagnosing leaks and provides unique information on the condition of the stomach. We believe it allows a more targeted approach to patient care in the context of anastomotic healing and in the treatment of leaks.
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Alizai PH, Mahnken AH, Klink CD, Neumann UP, Junge K. Extended distal pancreatectomy with en bloc resection of the celiac axis for locally advanced pancreatic cancer: a case report and review of the literature. Case Rep Med 2012; 2012:543167. [PMID: 22567019 PMCID: PMC3332186 DOI: 10.1155/2012/543167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 01/23/2012] [Accepted: 01/24/2012] [Indexed: 01/12/2023] Open
Abstract
Due to a lack of early symptoms, pancreatic cancers of the body and tail are discovered mostly at advanced stages. These locally advanced cancers often involve the celiac axis or the common hepatic artery and are therefore declared unresectable. The extended distal pancreatectomy with en bloc resection of the celiac artery may offer a chance of complete resection. We present the case of a 48-year-old female with pancreatic body cancer invading the celiac axis. The patient underwent laparoscopy to exclude hepatic and peritoneal metastasis. Subsequently, a selective embolization of the common hepatic artery was performed to enlarge arterial flow to the hepatobiliary system and the stomach via the pancreatoduodenal arcades from the superior mesenteric artery. Fifteen days after embolization, the extended distal pancreatectomy with splenectomy and en bloc resection of the celiac axis was carried out. The postoperative course was uneventful, and complete tumor resection was achieved. This case report and a review of the literature show the feasibility and safety of the extended distal pancreatectomy with en bloc resection of the celiac axis. A preoperative embolization of the celiac axis may avoid ischemia-related complications of the stomach or the liver.
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Affiliation(s)
- Patrick H. Alizai
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Andreas H. Mahnken
- Department of Diagnostic and Interventional Radiology, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Christian D. Klink
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Ulf P. Neumann
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Karsten Junge
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
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Vander Heide R. Clinically useful cardioprotection: ischemic preconditioning then and now. J Cardiovasc Pharmacol Ther 2012; 16:251-4. [PMID: 21821524 DOI: 10.1177/1074248411407070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ischemic preconditioning (IP) is the most effective, reproducible form of protection against myocardial cell death yet described. The mechanism of classic IP has not been identified, but recent investigations have focused on the mitochondrial permeability transition pore (mPTP). Similarly, the mechanism of the "second window of protection" (SWOP) is not known but thought to involve increased expression of important gene products. Currently, IP in the clinical arena is limited to cardiac surgery, planned angioplasty, and organ preservation protocols. To move preconditioning into a broader clinical arena will require resolution of important fundamental yet stubborn problems involving both basic and clinical science. Important unresolved issues include the mechanisms involved in the transition from reversible to irreversible injury, the amount of potential salvageable myocardium present at the onset of reperfusion, the identity and signaling of the mPTP, the optimization of protocols, the identity of end effectors (SWOP), and the identification of the best experimental model systems. From a clinical standpoint, important issues include the influence of comorbidities on cardioprotection, identification of appropriate animal models, the lack of a biologic marker of the cardioprotective state, the influence of coexistent therapeutic drugs, potential toxicity of pharmacologic mimics, and the window of opportunity for significant protection. Ischemic preconditioning has yielded promising results in other organs including the brain as well as tissue preservation for certain surgical procedures that will require definition of the underlying mechanism(s) to be fully exploited clinically. Over the past 25 years, the scientific community has learned much regarding the biology and potential mechanisms of IP and the concept has been expanded to many other organ systems in many other clinically relevant scenarios. To realize the full clinical potential will require continued investigation into the mechanism.
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Affiliation(s)
- Richard Vander Heide
- Pathology Department, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
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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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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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Veeramootoo D, Taylor C, Wajed SA. Minimally invasive esophagectomy with two-field lymphadenectomy. Surg Endosc 2011; 25:3110-5. [DOI: 10.1007/s00464-011-1625-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 03/19/2010] [Indexed: 01/08/2023]
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32
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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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Esophageal replacement following gastric devascularization is safe, feasible, and may decrease anastomotic complications. J Gastrointest Surg 2010; 14:1069-73. [PMID: 20473579 DOI: 10.1007/s11605-010-1204-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 04/12/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric transposition is the most common reconstruction after esophagectomy. Despite technical improvements, the incidence of anastomotic complications remains high. Gastric devascularization followed by esophageal resection and reconstruction has been proposed to minimize these complications. METHODS Thirty-two patients underwent minimally invasive esophagectomy, and seven high-risk patients were selected for laparoscopic gastric devascularization performed either 1 week (n = 5) or 12 weeks (n = 2) before esophageal resection. Primary outcomes included anastomotic leak and stricture. RESULTS Each patient underwent successful laparoscopic devascularization and subsequent esophagectomy. Devascularization required an average of 134 minutes with minimal operative blood loss. There were no complications following gastric devascularization or directly attributable to delay. None of the delay patients developed an anastomotic leak, compared to 16% of patients after immediate reconstruction (p = 0.258). One patient (14%) developed an anastomotic stricture that required endoscopic dilatation within the first year after surgery, compared to 12% of immediate reconstruction patients (p = 0.872). CONCLUSION In this series, all patients underwent successful delayed reconstruction following gastric devascularization without anastomotic leak. The absence of anastomotic leak in the delay group suggests that delayed conduit preparation can be accomplished safely while potentially reducing the morbidity associated with esophagectomy, but larger prospective studies are required to prove this definitively.
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