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Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study

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Abstract

Background

Gastric ischemic preconditioning prior to esophagectomy has been studied as a method to improve gastric conduit perfusion and reduce anastomotic complications, without conclusive results. The aim of this study is to evaluate the feasibility and safety of gastric ischemic preconditioning in terms of post-operative outcomes and quantitative gastric conduit perfusion.

Methods

Patients who underwent an esophagectomy with gastric conduit reconstruction between January 2015 and October 2022 at a single high-volume academic center were reviewed. Patient characteristics, surgical approach, post-operative outcomes, and indocyanine green fluorescence angiography data (ingress index for arterial inflow and ingress time for venous outflow, and the distance from the last gastroepiploic branch to the perfusion assessment point) were analyzed. Two propensity score weighting methods were used to investigate whether gastric ischemic preconditioning reduces anastomotic leaks. Multiple linear regression analysis was used to evaluate the conduit perfusion quantitatively.

Results

There were 594 esophagectomies with gastric conduit performed, with 41 having a gastric ischemic preconditioning. Among 544 with cervical anastomoses, leaks were seen in 2/30 (6.7%) in the ischemic preconditioning group and 114/514 (22.2%) in the control group (p = 0.041). Gastric ischemic preconditioning significantly reduced anastomotic leaks on both weighting methods (p = 0.037 and 0.047, respectively). Ingress index and time of the gastric conduit with ischemic preconditioning were significantly better than those without preconditioning (p = 0.013 and 0.025, respectively) after removing the effect of the distance from the last gastroepiploic branch to the perfusion assessment point.

Conclusion

Gastric ischemic preconditioning results in a statistically significant improvement in conduit perfusion and reduction in post-operative anastomotic leaks.

Graphical abstract

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Fig. 1
Fig. 2

© system generates the perfusion images, but also this graph in real time. An ingress triangle is automatically drawn based on the “inflow” of indocyanine green dye and then values are provided as a target region is set

Fig. 3
Fig. 4

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Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

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Authors and Affiliations

  1. Section of Thoracic Surgery, Department of Surgery, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA

    Yoshitaka Ishikawa, Andrew C. Chang, Jules Lin, Mark B. Orringer, William R. Lynch, Kiran H. Lagisetty, Elliot Wakeam & Rishindra M. Reddy

  2. Department of Biostatistics, University of Michigan, SPH II, 1415 Washington Heights M4509, Ann Arbor, MI, 48109, USA

    Lili Zhao

  3. Division of Thoracic Surgery, Department of Surgery, University of Virginia Health, 1240 Lee Street, Charlottesville, VA, 22903, USA

    Philip W. Carrott

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  1. Yoshitaka Ishikawa
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Corresponding author

Correspondence to Rishindra M. Reddy.

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Disclosures

Rishindra M. Reddy has received honorariums from Intuitive Surgical for being a speaker and proctor, from Genentech serving on an Advisory Board, from Medtronic serving on an Advisory Board, from Auris Health serving as a Consultant, from Atricure serving on an Advisory Board, and research funds from On Target Labs. Jules Lin has received honorariums from Intuitive Surgical for being a speaker and proctor. Yoshitaka Ishikawa, Lili Zhao, Philip W. Carrott, Andrew C. Chang, Mark B. Orringer, William R. Lynch, Kiran H. Lagisetty, and Elliot Wakeam have no conflicts of interest to disclose.

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Ishikawa, Y., Zhao, L., Carrott, P.W. et al. Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study. Surg Endosc 37, 6989–6997 (2023). https://doi.org/10.1007/s00464-023-10191-x

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