Search

Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14 days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12–18 days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45 minutes (range: 25–230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2 days (range: 2–4 days). Esophagectomy was completed in all patients after a median of 14 days (range: 12–28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.

Background Acute gastric conduit necrosis (AGCN) is a serious early complication of esophagectomy that can result in loss of the gastric conduit. The reported incidence is relatively low: 0.5-3.2%. Literature is thus scarce. However, vascular comorbidity has been shown to be a risk factor. This study aimed to assess the arterial calcification scores, clinical presentation, management, and outcome of patients who suffered from AGCN following esophagectomy in a high volume centre for esophageal cancer surgery. Methods Patients who underwent esophagectomy for esophageal cancer were selected (Jan-2011 till Feb-2019) from a prospectively maintained single-centre database that contains the patient characteristics, treatment details, and postoperative outcomes of all patients undergoing esophagogastric surgery. For the AGCN cases, additional information regarding their clinical course was retrieved from the electronic patient files. Arterial calcification scores were established by measuring calcifications at 4 arterial locations on preoperative computed tomography (CT) scans. Results From a total of 466 esophagectomies performed in the inclusion period, AGCN occurred in 8 cases (1.7%). Resection of the gastric conduit was required in 5 of these patients, of whom 3 patients had a fatal outcome. The other patients were successfully treated by conservative treatment involving a nil by mouth regimen (n=2) or a self-expanding metal stent (n=1). There was a high prevalence of supra-aortic (75%) and thoracic (87.5%) calcifications in the patients suffering from AGCN. Conclusion AGCN is a rare but serious complication following esophagectomy, with a high mortality. Patients with generalized vascular disease may be at particular risk of developing this complication.