Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging in an experimental model for minimally invasive esophagectomy

Abstract

Objective: To optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis. Summary Background Data: Esophagectomy is the mainstay of esophageal cancer treatment but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome. Methods: A live porcine model (n=50) for MIE was used with gastric conduit formation and linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic site was evaluated using HSI and was validated with histopathology. Results: The tissue oxygenation (ΔStO2) after the anastomosis remained constant only for the short stapler in caudal position (-0.4±4.4%, n.s.) while it dropped markedly in the other groups (short-cranial: -15.6±11.5%, p=0.0002; long-cranial: -20.4±7.6%, p=0.0126; long-caudal: -16.1±9.4%, p<0.0001) Tissue samples from deoxygenated stomach as measured by HSI showed correspondent eosinophilic pre-necrotic changes in 35.7±9.7% of the surface area. Conclusions: Tissue oxygenation at the anastomotic site of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. These findings allow for optimization of gastric conduit perfusion and anastomotic technique in MIE.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis

“…RR, risk ratio; 95% CI, confidence interval a larger anastomotic diameter, minimizes problems related to visceral mismatch, and makes an extroverted anastomosis which leads to improved mucosa-to-mucosa apposition [29,37]. Furthermore, it has been postulated that LS might be advantageous in terms of blood supply as the staple line results parallel to the axis of the gastric conduit thus leading to maximum preservation of the vasculature network at the anastomosis mainly perfused through intramural capillaries anastomotic site [62]. Finally, LS anastomosis requires a longer esophageal remnant (at least 2 cm); thus, fashioning an aligned high intra-thoracic tension-free anastomosis is challenging because of limited space.…”

Hyperspectral Imaging for the Evaluation of Microcirculatory Tissue Oxygenation and Perfusion Quality in Haemorrhagic Shock: A Porcine Study

“…Hyperspectral imaging (HSI) is an evolving noninvasive imaging technology that provides an evaluation of intrinsic biochemical tissue characteristics based on tissue-light interactions [ 4 ]. HSI technologies are increasingly being investigated in surgical research for real-time intraoperative organ perfusion-based resection planning and optimization of anastomosis quality [ 5 , 6 , 7 ]. Data on HSI technologies for microcirculatory monitoring of haemodynamic therapy in critically ill or surgical patients are limited.…”

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

“…Physiologic gastric perfusion is supported by large capillaries, distributed perpendicular to both gastric curvatures, and by small capillary branches that run parallel to both curvatures thus forming a complex vascular network. 55 Ligation of the left gastric artery, left gastroepiploic artery, and short gastric vessels determine a reorganization of this network. Therefore, perfusion dynamics in the gastric conduit occur through the right gastroepiploic artery at the greater curvature while the tip of the conduit relies on small longitudinally oriented collateral connections.…”