Preventing Anastomotic Complications: Early Results of Laparoscopic Gastric Devascularization Two Weeks Before Minimally Invasive Esophagectomy

David S Strosberg, MD, Jennifer S Schwartz, MD, Maelee Yang, BS, Robert E Merritt, MD, Kyle A Perry, MD. The Ohio State University Wexner Medical Center

Introduction: Anastomotic complications resulting from ischemic changes in the gastric fundus remain a major cause of surgical morbidity following esophagectomy with gastric pull-up reconstruction. Laparoscopic gastric devascularization (LGD) proposes an innovative method to improve gastric conduit perfusion and improve anastomotic healing to date. Clinical studies with LGD performed 4 to 7 days before esophagectomy have produced inconsistent results; however, preclinical studies suggest that a longer ischemic conditioning time may be required to achieve the desired changes in gastric perfusion. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis.

Methods: We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor-Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with mobilization of the stomach including division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient data are maintained in a prospectively collected, IRB approved database, and variables of interest for this study included patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission and complications.

Results: Thirty patients underwent LGD prior to minimally invasive Ivor-Lewis esophagectomy, and 21 (70%) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9-42) days prior to esophagectomy. Median operative time was 39 (18-56) minutes, and median length of stay was 0 (0-1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93% of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17%) were readmitted within 60 days of surgery: 1 (3%) patient with an anastomotic leak, 2 (7%) with pneumonia, and 2 (7%) with post-operative nausea and vomiting. One patient (3%) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period.

Conclusions: LGD with delayed esophageal resection and reconstruction can be safely performed 2 weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3%) and absence of anastomotic strictures in this series suggests that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single stage approaches. However, larger comparative studies are required to directly compare the outcomes of this approach to those of single-stage Ivor-Lewis esophagectomy.

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