Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

Abstract

Background: Ischemia at the anastomotic site is a critical protagonist 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. 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 (CrI) 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 vs. noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC vs. noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC vs. noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC vs. 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 vs. AngioGIC in term 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.

The impact of minimally-invasive esophagectomy operative duration on post-operative outcomes

“…By evaluating surgeries that were completed minimally-invasively, rather than open, we may have inadvertently selected for less complex cases, although many variables suggest that these are complex patients (4.4% had undergone prior cardiothoracic surgery, 66.0% were clinical stage III, and 89.6% and 84.5% had received neoadjuvant chemotherapy and radiation, respectively). We also did not collect data on some technical factors that may impact complication rates and mortality, including intra-operative blood loss, ischemic preconditioning and anastomotic technique ( 23 , 24 ), nor did we include data on facility or surgeon MIE volume ( 25 ). However, a prior study in our health system demonstrated that regionalization of esophagectomy care to several Centers of Excellence was associated with decreased rates of complication, while surgeon and facility volume were not ( 26 ).…”