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Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy

Abstract

Background:

Laparoscopic gastric devascularization (LGD) is an innovative method to improve gastric conduit perfusion and improve anastomotic healing following esophagectomy. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis.

Methods:

We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission, and complications were collected and analyzed.

Results:

Thirty patients underwent LGD prior to minimally invasive Ivor Lewis esophagectomy, and 21 (70 %) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9–42) days prior to esophagectomy. Median operative time was 39 (18–56) minutes, and median length of stay was 0 (0–1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93 % of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17 %) were readmitted within 60 days of surgery: one (3 %) patient with an anastomotic leak, two (7 %) with pneumonia, and two (7 %) with post-operative nausea and vomiting. One patient (3 %) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period.

Conclusions:

LGD with delayed esophageal resection and reconstruction can be safely performed two weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3 %) and absence of anastomotic strictures in this series suggest that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single-stage approaches.

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References

  1. 1.

    Pohl H, Welch HG (2005) The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence. J Natl Cancer Inst 97(2):142–146

  2. 2.

    Pham TH, Perry KA, Enestvedt CK, Enestvedt CK, Gareau D, Dolan JP, Sheppard BC, Jacques SL, Hunter JG (2011) Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications. Ann Thorac Surg 91(2):380–385

  3. 3.

    Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH, D’Amico TA (2004) Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 78(4):1170–1176

  4. 4.

    Bludau M, Holscher AH, Vallbohmer D, Gutschow C, Schroder W (2010) Ischemic conditioning of the gastric conduit prior to esophagectomy improves mucosal oxygen saturation. Ann Thorac Surg 90(4):1121–1126

  5. 5.

    Veeramootoo D, Shore AC, Wajed SA (2012) Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial. Surg Endosc 26(7):1822–1829

  6. 6.

    Schroder W, Holscher AH, Bludau M, Vallbohmer D, Bollschweiler E, Gutschow C (2010) Ivor-Lewis esophagectomy with and without laparoscopic conditioning of the gastric conduit. World J Surg 34(4):738–743

  7. 7.

    Perry KA, Banarjee A, Liu J, Shah N, Wendling MR, Melvin WS (2013) Gastric ischemic conditioning increases neovascularization and reduces inflammation and fibrosis during gastroesophageal anastomotic healing. Surg Endosc 27(3):753–760

  8. 8.

    Kechagias A, van Rossum PS, Ruurda JP, van Hillegersberg R (2016) Ischemic conditioning of the stomach in the prevention of esophagogastric anastomotic leakage after esophagectomy. Ann Thorac Surg 101:1614–1623

  9. 9.

    Morse BC, Simpson JP, Jones YR, Johnson BL, Knott BM, Kotrady JA (2013) Determination of independent predictive factors for anastomotic leak: analysis of 682 intestinal anastomoses. Am J Surg 206(6):950–955

  10. 10.

    Urschel JD (1995) Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 169(6):634–640

  11. 11.

    Kraemer R, Lorenzen J, Kabbani M, Herold C, Busche M, Vogt PM, Knobloch K (2011) Acute effects of remote ischemic preconditioning on cutaneous microcirculation—a controlled prospective cohort study. BMC Surg 11:32

  12. 12.

    Yuan Y, Duranceau A, Ferraro P, Martin J, Liberman M (2012) Vascular conditioning of the stomach before esophageal reconstruction by gastric interposition. Dis Esophagus: Off J Int Soc Dis Esophagus/I.S.D.E. Nov–Dec 2012 25(8):740–749

  13. 13.

    Perry KA, Enestvedt CK, Pham TH, Dolan JP, Hunter JG (2010) Esophageal replacement following gastric devascularization is safe, feasible, and may decrease anastomotic complications. J Gastrointest Surg: Off J Soc Surg Aliment Tract 14(7):1069–1073

  14. 14.

    Yetasook AK, Leung D, Howington JA, Talamonti MS, Zhao J, Carbray JM, Ujiki MB (2013) Laparoscopic ischemic conditioning of the stomach prior to esophagectomy. Dis Esophagus: Off J Int Soc Dis Esophagus 26(5):479–486

  15. 15.

    Wajed SA, Veeramootoo D, Shore AC (2012) Video surgical optimisation of the gastric conduit for minimally invasive oesophagectomy. Surg Endosc 26(1):271–276

  16. 16.

    Urschel JD, Takita H, Antkowiak JG (1997) The effect of ischemic conditioning on gastric wound healing in the rat: implications for esophageal replacement with stomach. J Cardiovasc Surg 38(5):535–538

  17. 17.

    Urschel JD, Antkowiak JG, Delacure MD, Takita H (1997) Ischemic conditioning (delay phenomenon) improves esophagogastric anastomotic wound healing in the rat. J Surg Oncol 66(4):254–256

  18. 18.

    Nguyen NT, Nguyen XM, Reavis KM, Elliott C, Masoomi H, Stamos MJ (2012) Minimally invasive esophagectomy with and without gastric ischemic conditioning. Surg Endosc 26(6):1637–1641

  19. 19.

    Veeramootoo D, Shore AC, Shields B, Krishnadas R, Cooper M, Berrisford RG, Wajed SA (2010) Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy. Surg Endosc 24(5):1126–1131

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Author information

Correspondence to Kyle A. Perry.

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Disclosures

David Strosberg, Robert Merritt and Kyle Perry have no conflicts of interest or financial ties to disclose.

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Strosberg, D.S., Merritt, R.E. & Perry, K.A. Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy. Surg Endosc 31, 1371–1375 (2017). https://doi.org/10.1007/s00464-016-5122-4

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Keywords

  • Laparoscopic gastric devascularization
  • Minimally invasive esophagectomy
  • Anastomotic leak
  • Anastomotic stricture
  • Esophageal cancer