Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue

Abstract

Introduction Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis. Methods Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified. Results Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51–155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447). Conclusions In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon’s experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.

Diaphragmatic herniation following esophagogastric resectional surgery: an increasing problem with minimally invasive techniques?

“…Advantages of minimal access approaches to the esophagus include a lower risk of postoperative chest infection, shorter length of stay, quicker return to work and post-operative recovery [2][3][4]. There are cited disadvantages, including higher rates of gastric conduit necrosis and anastomotic leak [5,6]. In addition, there are increasing reports of diaphragmatic herniation following esophagectomy performed using minimally invasive techniques [7,8].…”

Transthoracic Extracorporeal Gastric Conduit Preparation for Minimally Invasive Ivor-Lewis Esophagectomy

“…Additional potential shortcomings of a laparoscopic conduit preparation include risk of torsion of a slender conduit on delivery from the abdomen into the chest, risk of separation of conduit from the specimen upon delivery, inability to palpate the gastroepiploic arcade, and trauma from handling of the stomach with graspers. 1,10,13 Minimally invasive Ivor-Lewis esophagectomy with transthoracic extracorporeal gastric conduit preparation has the potential to mitigate the shortcomings of laparoscopic conduit preparation. This technique of transthoracic conduit preparation was developed at our institution in response to a challenging case of distal esophageal cancer.…”

“…1,2 Minimally invasive Ivor-Lewis esophagectomy has been shown to allow more rapid postoperative recovery with equivalent short-and long-term oncologic outcomes, morbidity, and cost compared with the open technique. 3Y8 The approach to ILMIE involves laparoscopic creation of the tubularized gastric conduit.…”

Esofagectomía mínimamente invasiva: muchos procedimientos, muchos maestros

“…Osugi et al reportan reducción del tiempo quirúrgico, sangrado, complicaciones pulmonares e incremento en los ganglios disecados después de 34 casos, mientras que Guo et al establecen que 30 procedimientos son necesarios y se logra una reducción aún más significativa en morbilidad al completar los 60 casos. Por otro lado, Ramage et al observaron una reducción de complicaciones relacionadas con el tubo gástrico después de los 50 casos 1,[9][10][11] .…”