Vascular conditioning of the stomach before esophageal reconstruction by gastric interposition

Abstract

Gastric interposition with intrathoracic or cervical esophagogastrostomy is currently the preferred operation for reconstruction after esophagectomy. Anastomotic leaks however result from poor vascular supply to the proximal stomach. They are responsible for significant morbidity and mortality. 'Ischemic conditioning' of the interposed stomach has been proposed as a technique where the 'delay phenomenon' aims at improving the microcirculation of the gastric conduit and preventing anastomotic leakage. Experimental observations and clinical studies have been conducted to document the immediate effects and results of this approach. The aim of this work is to review the principles, pathophysiology, experimental, and clinical evidence related to vascular conditioning of the stomach prior to esophagectomy with gastric interposition and esophagogastric anastomosis. MEDLINE and PubMed were searched to identify articles related to vascular conditioning of the stomach. Cross references were added and reviewed to complete the reference list. The anatomic basis of ischemic conditioning, the prevalence of ischemic events on the gastric conduit, the methodology to assess the microcirculation before and after gastric devascularization, animal experiments, and clinical studies reported on this approach were reviewed. Ten experimental works, eleven clinical observations, four reviews, and two editorial commentaries addressing ischemic conditioning of the stomach were identified and reviewed. Experimental observations document improved microcirculation to the proximal stomach following partial gastric devascularization. Clinical reports show the feasibility and relative safety of gastric ischemic conditioning. Preliminary observations suggest potential improvements to the gastric microcirculation resulting from gastric ischemic conditioning. This approach may help prevent complications at the esophagogastric anastomosis. The actual level of evidence however cannot promote its use outside of clinical research protocols.

Laparoscopic ischemic conditioning of the stomach increases neovascularization of the gastric conduit in patients undergoing esophagectomy for cancer

“…A recent review on the topic of microcirculation following ischemic conditioning found ten studies that demonstrated improved circulation at the gastric conduit tip following ischemic conditioning. 19 There were a number of different methods used to assess the 19 For our study, we elected to perform microvessel counts of postoperative biopsy specimens at the conduit tip. This method was well suited for our purposes, because it provided a quantitative measurement, did not add an additional step to the operative procedure, and allowed us to take advantage of our database of available surgical specimens.…”

“…As a result, a number of techniques have been devised to improve blood flow to the gastric conduit. These methods include anastomosing donor vessels to the gastric circulation, use of a pedicled omental flap around the anastomosis, phlebotomy through the short gastric veins to decrease vascular congestion, and delayed anastomosis with gastric ischemic conditioning . The basis of ischemic conditioning is that perfusion to conduit tip can be enhanced by ligation of select vessels to the stomach prior to esophagogastrostomy, allowing new microcirculation to develop to the gastric fundus at the site of the anastomosis.…”

“…The basis of ischemic conditioning is that perfusion to conduit tip can be enhanced by ligation of select vessels to the stomach prior to esophagogastrostomy, allowing new microcirculation to develop to the gastric fundus at the site of the anastomosis. A recent review on the topic of microcirculation following ischemic conditioning found ten studies that demonstrated improved circulation at the gastric conduit tip following ischemic conditioning . There were a number of different methods used to assess the microvasculature of the gastric conduit, including contrast enhanced ultrasound, laser Doppler flowmetry, reflectance spectrophotometry, and clearance techniques of various tracers .…”

“…A recent review on the topic of microcirculation following ischemic conditioning found ten studies that demonstrated improved circulation at the gastric conduit tip following ischemic conditioning . There were a number of different methods used to assess the microvasculature of the gastric conduit, including contrast enhanced ultrasound, laser Doppler flowmetry, reflectance spectrophotometry, and clearance techniques of various tracers . For our study, we elected to perform microvessel counts of postoperative biopsy specimens at the conduit tip.…”

“…These methods include anastomosing donor vessels to the gastric circulation, use of a pedicled omental flap around the anastomosis, phlebotomy through the short gastric veins to decrease vascular congestion, and delayed anastomosis with gastric ischemic conditioning. 19 The basis of ischemic conditioning is that perfusion to conduit tip can be enhanced by ligation of select vessels to the stomach prior to esophagogastrostomy, allowing new microcirculation to develop to the gastric fundus at the site of the anastomosis. A recent review on the topic of microcirculation following ischemic conditioning found ten studies that demonstrated improved circulation at the gastric conduit tip following ischemic conditioning.…”