Results of minimally invasive esophagectomy for esophageal cancer performed after ischemic gastric conditioning

Abstract

Introduction: Esophageal tumor resections are extensive procedures with high postoperative complication rates including anastomotic leak. An anastomotic leak occurs when microcirculation in the proximal gastric wall used for esophageal replacement is impaired. Preoperative occlusion of certain gastric vessels (ischemic gastric conditioning) may lead to changes in vascularization and can potentially reduce the occurrence and severity of anastomotic leak after esophageal resection.
Method: This is a retrospective data analysis of patients with esophageal cancer operated on in the Department of Surgery at University Hospital in Brno after previous ischemic gastric conditioning.
Results: Preoperatively, IC was performed by means of a radiological method in 7 patients (embolisation of the left gastric artery). In another 68 patients, a diagnostic laparoscopy was performed and the left gastric artery was surgically divided. During the laparoscopy, a nutritional jejunostomy was performed to enhance nutrition supply in 44 patients with food intake issues due to a stenotizing tumor. In 15 cases, a biopsy from suspicious formations in the abdominal cavity was harvested. In 5 patients, the biopsies revealed malignant disease which had not been discovered with staging radiologic diagnostic methods. After radiological ischemic conditioning, spleen ischemia was found in 2 patients after esophageal resection, and therefore we did not continue to use this method. After surgical gastric ischemic conditioning, 39 mini-invasive esophageal resections were performed. 2 of the resected patients died after the operation (5.1%). Anastomotic leak was found in a total of 8 patients after the resection. In 6 patients with anastomotic leak, management was not complicated and no reoperation was needed. No patient had complete necrosis of the gastric conduit due to ischemia.
Conclusion: Staging laparoscopy is a safe method beneficial for patients with esophageal cancer. It offers exploration of the abdominal cavity to rule out small peritoneal and liver metastases and nutritional jejunostomy for nutrition intake improvement can be done. Ischemic conditioning can also be performed during laparoscopy which may enhance vascularization of the gastric conduit used for esophageal replacement and, despite the fact that it does not reduce the incidence of anastomotic leak, it may reduce its severity. There are no exact recommendations about adequate time delay between ischemic conditioning and esophageal resection. Performing esophageal resection is not altered by previous ischemic gastric conditioning.