Critical appraisal of gastric conduit ischaemic conditioning (GIC) prior to oesophagectomy: A systematic review and meta-analysis

Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis

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.

Pilot Trial on Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer: Feasibility and Impact on Anastomotic Leakage (TIGOAL-I)

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.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy induces gastric neo-angiogenesis

BACKGROUND

The risk of an anastomotic leakage (AL) following Ivor-Lewis esophagectomy is increased in patients with calcifications of the aorta or a stenosis of the celiac trunc. Ischemic conditioning (ISCON) of the gastric conduit prior to esophagectomy is supposed to improve gastric vascularization at the anastomotic site. The prospective ISCON trial was conducted to proof the safety and feasibility of this strategy with partial gastric devascularization 14 days before esophagectomy in esophageal cancer patients with a compromised vascular status. This work reports the results from a translational project of the ISCON trial aimed to investigate variables of neo-angiogenesis.

METHODS

Twenty esophageal cancer patients scheduled for esophagectomy were included in the ISCON trial. Serum samples (n = 11) were collected for measurement of biomarkers and biopsies (n = 12) of the gastric fundus were taken before and after ISCON of the gastric conduit. Serum samples were analyzed including 62 different cytokines. Vascularization of the gastric mucosa was assessed on paraffin-embedded sections stained against CD34 to detect the degree of microvascular density and vessel size.

RESULTS

Between November 2019 and January 2022 patients were included in the ISCON Trial. While serum samples showed no differences regarding cytokine levels before and after ISCON biopsies of the gastric mucosa demonstrated a significant increase in microvascular density after ISCON as compared to the corresponding gastric sample before the intervention.

CONCLUSION

The data prove that ISCON of the gastric conduit as esophageal substitute induces significant neo-angiogenesis in the gastric fundus which is considered as surrogate of an improved vascularization at the anastomotic site.

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study

BACKGROUND

Gastric ischemic preconditioning prior to esophagectomy has been studied as a method to improve gastric conduit perfusion and reduce anastomotic complications, without conclusive results. The aim of this study is to evaluate the feasibility and safety of gastric ischemic preconditioning in terms of post-operative outcomes and quantitative gastric conduit perfusion.

METHODS

Patients who underwent an esophagectomy with gastric conduit reconstruction between January 2015 and October 2022 at a single high-volume academic center were reviewed. Patient characteristics, surgical approach, post-operative outcomes, and indocyanine green fluorescence angiography data (ingress index for arterial inflow and ingress time for venous outflow, and the distance from the last gastroepiploic branch to the perfusion assessment point) were analyzed. Two propensity score weighting methods were used to investigate whether gastric ischemic preconditioning reduces anastomotic leaks. Multiple linear regression analysis was used to evaluate the conduit perfusion quantitatively.

RESULTS

There were 594 esophagectomies with gastric conduit performed, with 41 having a gastric ischemic preconditioning. Among 544 with cervical anastomoses, leaks were seen in 2/30 (6.7%) in the ischemic preconditioning group and 114/514 (22.2%) in the control group (p = 0.041). Gastric ischemic preconditioning significantly reduced anastomotic leaks on both weighting methods (p = 0.037 and 0.047, respectively). Ingress index and time of the gastric conduit with ischemic preconditioning were significantly better than those without preconditioning (p = 0.013 and 0.025, respectively) after removing the effect of the distance from the last gastroepiploic branch to the perfusion assessment point.

CONCLUSION

Gastric ischemic preconditioning results in a statistically significant improvement in conduit perfusion and reduction in post-operative anastomotic leaks.

Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis

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.

What has the past taught us about the future in esophageal cancer? Personal reflections

Since the first successful esophagectomy for cancer in 1913 spectacular advancements have been made in diagnosis, staging, and therapy. Refinement of imaging, surgery, perioperative management together with multidisciplinary collaboration are the cornerstones. Today therapy with curative option is offered to more patients than ever. Further innovations in imaging, molecular biology, genetics, artificial intelligence, machine learning, robotics, nanotechnology will have an increasing impact. The end result being a unique therapeutic plan shaped on each patient's individual profile.

Risk Factors and Effect of Intrathoracic Anastomotic Leakage after Esophagectomy for Underlying Malignancy-A Ten-Year Analysis at a Tertiary University Centre

Aim: Surgical resection remains the treatment of choice for curable esophageal cancer patients. Anastomotic leakage after esophagectomy with an intrathoracic anastomosis is the most feared complication, and is the main cause of postoperative morbidity and mortality. The aim of this study was to identify risk factors associated with anastomotic leakage and its effect on the postoperative outcome. Methods: Between 2012 and 2022, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. We performed a retrospective analysis of 174 patients. The dataset was analyzed to identify risk factors for the occurrence of anastomotic leakage. Results: A total of 174 patients were evaluated. The overall anastomotic leakage rate was 18.96%. The 30-day mortality rate was 8.62%. Multivariate logistic regression analysis identified diabetes (p = 0.0020) and obesity (p = 0.027) as independent risk factors associated with anastomotic leakage. AL had a drastic effect on the combined ICU/IMC and overall hospital stay (p < 0.001. Conclusion: Anastomotic leakage after esophagectomy with intrathoracic anastomosis is the most feared complication and major cause of morbidity and mortality. Identifying risk factors preoperatively can contribute to better patient management.

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

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.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives

Simple Summary

Subtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome.

Abstract

Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.

Gastric ischemic conditioning prior to esophagectomy reduces anastomotic leaks and strictures: a systematic review and meta-analysis

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.

Perioperative management of patients with undergoing durable mechanical circulatory support

Durable mechanical circulatory support (MCS) devices revolutionized the treatment options for patients with end-stage heart failure (HF). Implantation of durable mechanical support has become an integral treatment modality in end-stage HF patients and it is associated with improved quality of life and survival. There is no doubt that this needs an interdisciplinary and interprofessional approach of cardiac surgeons, cardiologists, cardiac anesthesiologists, perfusionists, intensivists, psychologists, assist device coordinators as well as physiotherapists and intensive care. Implantation of durable MCS is a challenging procedure for the anesthesiologist due to the patient’s characteristics and comorbid diseases. It demands comprehensive training, high vigilance and quick response during the acute hemodynamic changes occurring during the surgery. Preoperative risk stratification is of major importance to guide perioperative medical treatment strategies. Most of these patients have several comorbidities and multiple medications. Therefore, to anticipate postoperative end-organ dysfunction such as cognitive dysfunction, pulmonary or renal failure, an interdisciplinary approach is necessary to optimize patient’s prior surgery. Transthoracic and transesophageal echocardiography (TTE and TEE), both play an invaluable role in diagnosing the cause and guiding the management in different unstable clinical situations. Especially prevention of postoperative right HF with subsequent necessity of temporary MCS is important as it is associated with higher mortality. The aim of this review is to provide an overview about the current concepts of perioperative management for durable MCS. A multimodal standard operating procedure supports early recovery after surgery and intensive care stay. Standardized perioperative care helps to ensure optimal medical treatment. This review focusses on several major skills of perioperative management of these high-risk surgical patients.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

Background

Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research.

Purpose

The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery.

Conclusions

There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.