INTRODUCTION: Gastric pull-up reconstruction is the most common approach to esophageal replacement after resection for malignant or end stage benign esophageal disease. Despite technical improvements, the incidence of anastomotic leak and stricture remain high. Gastric devascularization followed by delayed gastric conduit creation and esophageal resection has been proposed to minimize anastomotic complications. The aim of this study was to review the experience and outcomes of the delay technique applied in a high-risk esophagectomy cohort at a single institution.METHODS: Between July 2005 and June 2008, 32 patients underwent minimally invasive esophagectomy (MIE) by the combined thoracoscopic-laparoscopic approach. Seven patients deemed high risk for esophagectomy due to cardiopulmonary comorbidities were selected for laparoscopic ischemic pre-conditioning (LIP). Laparoscopic devascularization was performed either 1 week (n=5) or 12 weeks (n=2) before esophageal resection with gastric conduit reconstruction and included complete gastric mobilization with division of the short gastric vessels, left gastric artery, and coronary vein. Outcome measures included anastomotic leak measured by clinical and radiographic findings and the presence of symptomatic anastomotic stricture requiring endoscopic therapy.RESULTS: Each patient in the LIP group underwent successful laparoscopic devascularization and subsequent MIE. LIP required an average of 134 minutes to complete, and there was not a significant difference in mean operative time for MIE (494 min) compared to MIE with immediate reconstruction (545 min, p=0.141). There were no complications following LIP nor directly attributable to delay. None of the LIP patients developed an anastomotic leak postoperatively, compared to 17% of patients who underwent immediate reconstruction (p=0.237). One patient (14.3%) developed an anastomotic stricture that required endoscopic dilatation within the first year after surgery, compared to 6.4% of immediate reconstruction patients.CONCLUSION: In this series of high risk patients undergoing MIE for cancer, all of those chosen for LIP underwent successful delayed reconstruction following gastric devascularization without clinically or radiographically evident anastomotic leak. Despite the small sample size, the absence of anastomotic leak in the delay group suggests that delayed conduit preparation can be accomplished safely while potentially reducing the substantial morbidity associated with esophagectomy. Larger prospective studies are required to identify the patients who may benefit most from this approach.