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Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis

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Abstract

Ischemia at the anastomotic site is thought to be a protagonist in the development of anastomosis-related complications while different strategies to overcome this problem have been reported. Gastric ischemic conditioning (GIC) prior to esophagectomy has been described with this intent. Evaluate the effect of GIC on anastomotic complications after esophagectomy. Scopus, Web of Science, MEDLINE, and PubMed were investigated up to March 31st, 2023. We considered articles that appraised short-term outcomes after GIC vs. no GIC in patients undergoing esophagectomy. Anastomotic leak (AL), anastomotic stricture (AS), and gastric conduit necrosis (GCN) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Fourteen studies (1760 patients) were included. Of those, 732 (41.6%) underwent GIC, while 1028 (58.4%) underwent one-step esophagectomy. Compared with no GIC, GIC was related to a reduced RR for AL (R RR = 0.63; 95% CI 0.47–0.86; p < 0.01) and AS (RR = 0.51; 95% CI 0.29–0.91; p = 0.02), whereas no differences were found for GCN (RR = 0.56; 95% CI 0.19–1.61; p = 0.28). Postoperative pneumonia (RR = 1.09; p = 0.99), overall complications (RR = 0.87; p = 0.19), operative time (SMD − 0.58; p = 0.07), hospital stay (SMD 0.66; p = 0.09), and 30-day mortality (RR = 0.69; p = 0.22) were comparable. GIC prior to esophagectomy seems associated with a reduced risk for AL and AS. Further studies are necessary to identify the subset of patients who can benefit from this procedure, the optimal technique, and the timing of GIC prior to esophagectomy.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The article has been supported by AIRES (Associazione Italiana Ricerca ESofago). Members of Gastric Ischemic Conditioning (GIC) International Collaborative Group: Luigi Cayre1, Christian A. Gutschow2, John Lipham3, Michele Manara1, Călin Popa4, Emanuele Rausa5, Diana Schlanger4, Sebastian Schoppmann6, Aleksandar Simić7, Andrea Sozzi1, Joerg Zehetner8. 1I.R.C.C.S. Ospedale Galeazzi – Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Italy. 2Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. 3Division of General Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street HCC 4, Suite 6200, Los Angeles, CA 90033, USA; Division of Minimally Invasive Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street HCC 4, Suite 6200, Los Angeles, CA 90033, USA. 4Department of Surgery, Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca-Napoca, Romania. Street Emil Isac no 13, Cluj-Napoca-Napoca, 400023, Romania. 5Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy. 6Department of Surgery, Medical University of Vienna, Vienna, Austria. 7Department of Esophagogastric Surgery, University Hospital for Digestive Surgery, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia. 8Department of Visceral Surgery, Hirslanden Clinic Beau-Site, Berne, Switzerland.

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  1. I.R.C.C.S. Ospedale Galeazzi-Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy

    Alberto Aiolfi, Davide Bona & Gianluca Bonitta

  2. IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy

    Luigi Bonavina

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Gastric Ischemic Conditioning (GIC) International Collaborative Group

  • Luigi Cayre
  • , Christian A. Gutschow
  • , John Lipham
  • , Michele Manara
  • , Călin Popa
  • , Emanuele Rausa
  • , Diana Schlanger
  • , Sebastian Schoppmann
  • , Aleksandar Simić
  • , Andrea Sozzi
  •  & Joerg Zehetner

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Supplementary file1 Supplementary Figure 1. Risk of bias for Randomized Controlled Trials (RCT) was assessed with use of the Cochrane risk-of-bias tool. Green circle: Low risk of Bias. Red circle: High Risk of Bias. Yellow circle: Unclear Risk of Bias. (TIFF 161 KB)

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Aiolfi, A., Bona, D., Bonitta, G. et al. Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis. Updates Surg 75, 1633–1643 (2023). https://doi.org/10.1007/s13304-023-01601-9

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