Results of minimally invasive esophagectomy for esophageal cancer performed after ischemic gastric conditioning
Authors:
V. Procházka 1; T. Grolich 1; V. Čan 1; F. Marek 1; B. Bartušek 2; J. Ivičič 1; Z. Kala 1
Authors‘ workplace:
Chirurgická klinika Lékařské fakulty Masarykovy univerzity a Fakultní nemocnice Brno
1; Klinika radiologie a nukleární medicíny Lékařské fakulty Masarykovy univerzity a Fakultní nemocnice Brno
2
Published in:
Rozhl. Chir., 2018, roč. 97, č. 7, s. 335-341.
Category:
Original articles
Overview
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.
Keywords:
esophageal carcinoma – ischemic stomach conditioning – minimally invasive esophagectomy – anastomotic leak – anastomosis stenosis
Sources
- Duda M, Adamčík L, Dušek L, et al. Zhoubné nádory jícnu v České republice. Rozhl Chir 2012;91:132−40.
- Takeo Y, Yoshida T, Shigemitu T, et al. Endoscopic mucosal resection for early esophageal cancer and esophageal dysplasia. Hepatogastroenterology 2001;48:453−7.
- Liebermann-Meffert DM, Meier R, Siewert JR. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992;54:1110−5.
- Briel JW, Tamhankar AP, Hagen JA, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004;198:536−41.
- Zehetner J, DeMeester SR, Alicuben ET, et al. Intraoperative assessment of perfusion of the gastric graft and correlation with anastomotic leaks after esophagectomy. Ann Surg 2014;260:1030−3.
- Aujeský R, Neoral Č, Král V, et al. Videoasistovaná resekce jícnu pro karcinom – desetileté zkušenosti. Rozhl Chir 2010;89:746−9.
- Akiyama S, Ito S, Segikuchi H, et al. Preoperative embolisation of gastric arteries for esophageal cancer. Surgery 1996;120:542−6.
- Urschel JD, Takita H, Antkowiak JG. The effect of ischemic conditioning on gastric woung healing in the rat: implications for esophageal replacement with stomach. J Cardiovasc Surg 1997;38:535−
- Nguyen NT, Nguyen XM, Reavis KM, et al. Minimally invasive esophagectomy with and without gastric ischemic conditioning. Surgical Endoscopy 2012;26:1637−41.
- Hölscher AH, Schneider PM, Gutschow Ch, et al. Laparoscopic ischemic conditioning of the stomach for esophageal replacement. Ann Surg 2007;245:241−6.
- Perry KA, Banarjee A, Liu J, Shah N, et al. Gastric ischemic conditioning increases neovascularization and reduces inflammation and fibrosis during gastroesophageal anastomotic healing. Surg Endosc 2013;27:753−60.
- Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1.000 patients. Ann Surg 2012;256:95−103.
- Veeramootoo D, Parameswaran R, Krishnadas R, et al. Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy. Surg Endosc 2009;23:2010−6.
- Diana M, Hübner M, Vuilleumier H, et al. Redistribution of gastric blood flow by embolisation of gastric arteries before esophagectomy. Ann Thorac Surg 2011;91:1546−51.
- Nguyen NT, Longoria M, Sabio A, et al. Preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy. Ann Thorac Surg 2006;81:2318−20.
- Bludau M, Hölscher AH, Vallböhmer D, et al. Ischemic conditioning of the gastric conduit prior to esophagectomy improves mucosal oxygen saturation. Ann Thorac Surg 2010;90:1121−6.
- Veeramootoo D, Shore AC, Wajed SA. Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial. Surgical Endoscopy 2012;26:1822−9.
- Lamas S, Azuara D, de Oca J, et al. Time course of necrosis/apoptosis and neovascularization during experimental gastric conditioning. Dis Esophagus 2008;21:370−6.
- Mittermair Ch, Klaus A, Scheidl S. Functional capillary density in ischemic conditioning: implications for esophageal resection with the gastric conduit. Am J Surg 2008;196:88−92.
- Reavis KM, Chang EY, Hunter JG, et al. Utilization of the delay phenomenon improves blood flow and reduces collagen deposition in esophagogastric anastomoses. Ann Surg 2005;241:736−45.
- Oezcelik A, Banki F, DeMeester SR, et al. Delayed esophagogastrostomy: a safe strategy for management of patients with ischemic gastric conduit at the time of esophagectomy. J Am Coll Surg 2009;208:1030−4.
- Matsuzaki Y, Edagawa M, Maeda M, et al. Beneficial effect of prostaglandin E1 on blood flow to the gastric tube after esophagectomy. Ann Thorac Surg 1999;67:908−10.
- Enestvedt CK, Hosack L, Hoppo T, et al. Recombinant vascular endothelial growth factor (165) gene therapy improves anastomotic healing in an animal model of ischemic esophagogastrostomy. Dis Esophagus 2012;25:456−64.
- Perry KA, Enestvedt CK, Pham Th, et al. Esophageal replacement following gastric devascularization is safe, feasible and may decrease anastomotic complications. J Gastrointest Surg 2010;14:1069−73.
- van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074−84.
- Heger P, Blank S, Diener MK, et al. Gastric preconditioning in advance of esophageal resection-systematic review and meta-analysis. J Gastrointest Surg 2017;21:1523−32.
- Ohi M, Toiyama Y, Mohri Y, et al. Prevalence of anastomotic leak and the impact of indocyanine green fluorescein imaging for evaluating blood flow in the gastric conduit following esophageal cancer surgery. Esophagus 2017;14:351−9.
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Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2018 Issue 7
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