Ischaemic conditioning of the stomach previous to esophageal surgery

Abstract

A gastric conduit is most frequently used for reconstruction in oesophageal surgery, and ischemia of the conduit is the most fragile aspect of the esophagogastric anastomosis with as consequence the anastomotic leakage. In order to avoid it, the concept of ischaemic conditioning of the stomach previous to surgery has been designed. The basis of ischemic conditioning is that interrupting vascularization of the stomach before making the anastomosis eases the gastric fundus adaptation to ischemic conditions. It consists of the interruption of the principal feeding arteries of the stomach (except the right gastroepiploic artery) weeks before esophagectomy. Previously published literature contemplates two different techniques: angiographic embolization or laparoscopic ligation or division of vessels. In this study, the anatomic and physio-pathologic background of ischemic preconditioning is described and the published current evidence is reviewed.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

“…Owing to divergent technical approaches, it is very difficult to draw conclusions. However, two recent meta-analyses of the current literature did not reveal a significant impact on AL rates [86,88]. Therefore, many early advocates have abandoned ischemic conditioning in routine cases and reserve this option for high-risk patients that might benefit from a two-stage approach [91].…”

A Novel Technique to Improve Anastomotic Perfusion Prior to Esophageal Surgery: Hybrid Ischemic Preconditioning of the Stomach. Preclinical Efficacy Proof in a Porcine Survival Model

“…Despite promising results in experimental studies, when translated to humans, IGP has failed to exhibit a clear advantage in terms of AL reduction following esophageal resection [ 10 , 11 , 12 , 13 , 14 ]. Yet, the clinical trials using IGP are highly heterogeneous in terms of technique (angiographic embolization [ 36 , 37 , 38 ] or laparoscopic vessels ligation [ 16 , 18 , 39 , 40 , 41 , 42 ]) and number of vessels involved, and they are mostly of retrospective nature.…”

“…This heterogeneity could account for the apparent clinical inefficacy of ischemic preconditioning. However, the severity of the anastomotic complications in patients who receive IGP seems to be milder as compared to patients who undergo esophagectomy without preconditioning [ 10 , 11 , 12 , 13 , 14 ].…”

“…Ischemic gastric preconditioning (IGP) has been previously proposed to improve the relative ischemia of the GCF by enhancing local microcirculation [ 10 , 11 , 12 ]. IGP consists in the partial devascularization of the stomach, using either an endovascular or a laparoscopic approach, several days or weeks before gastric pull-up and esophagogastric anastomosis completion.…”

“…IGP consists in the partial devascularization of the stomach, using either an endovascular or a laparoscopic approach, several days or weeks before gastric pull-up and esophagogastric anastomosis completion. Although IGP has shown promising results in experimental settings and is a recognized safe procedure, it has failed to show a significant AL rate decrease to justify its implementation in the clinical routine [ 10 , 11 , 12 , 13 , 14 ]. This probably results from the large heterogeneity in terms of adopted IGP protocols and importantly from a too short delay between IGP and esophagectomy.…”