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Clinical Outcomes Following Esophagectomy With and Without Laparoscopic Ischemic Gastric Pre-Conditioning
Lava Y. Patel*2, Sabha Ganai2, Brandon Johnson2, Craig S. Brown1,2, Matthew E. Gitelis2, Brittany Lapin2, Ki Wan Kim2, John A. Howington2, John G. Linn2, Mark S. Talamonti2, Michael Ujiki2
1Biological Sciences Division, University of Chicago Pritzker School of Medicine, Chicago, IL; 2Surgery, NorthShore University HealthSystem, Evanston, IL
Introduction: Little data is available regarding the effect of laparoscopic gastric ischemic preconditioning (LIP) on anastomotic complications following esophagectomy for esophageal cancer. In this study, we compare outcomes of one-staged esophagectomy with an esophagectomy preceded by LIP.
Methods: A retrospective review of 118 esophagectomies conducted at a single institution between October 2003 and October 2015 identified 77 patients who underwent LIP prior to esophagectomy and 41 patients who underwent a one-staged operation. Comparative statistics were performed using Student’s t-test, Mann-Whitney U rank sum test, chi-square or Fisher exact tests. Time-to-event analysis was performed using the Kaplan-Meier method, with the log-rank test used for comparisons between groups. A Cox proportional hazards model was used to identify independent predictors of survival using stepwise inclusion of multiple variables. Data are reported as means with standard deviations (SD) or medians with interquartile ranges (IQR). Median follow-up was 12.0 (4.3-49.0) vs 10.6 (3.0-30.9) months for one-stage and two-stage patients, respectively.
Results: Patients undergoing one-stage esophagectomy were older (69.4±10.3 vs 61.5±9.6 years, p<0.01), with no difference in sex (p=0.12) or BMI (p=0.40). The median time interval between preconditioning and esophagectomy was 7 days. Operative time for esophagectomy was less following preconditioning (265.7±83.8 vs 233.9±79.0 minutes, p=0.02), but total operative time was significantly longer with the staged approach (265.7±83.8 vs 337.8±86.3 minutes, p<0.01). Hospital length of stay following esophagectomy was significantly shorter in the pre-conditioned patients [11 (9-17) vs 8 (7-10) days, p<0.01] while total length of stay after a two-staged procedure was not significantly longer than the one-staged procedure (p=0.17). Preconditioning resulted in no difference in anastomotic leaks [10 (24.4%) for one-stage vs 10 (13.0%) for two-stage, p=0.12] or delayed gastric emptying (p=0.27) but resulted in a decreased rate of stricture [10 (24.4%) for one-stage vs 4 (5.2%) for two-stage, p<0.01]. Additionally, one-stage esophagectomy resulted in an increased rate of total complications compared to two-stage esophagectomy [34 (82.9%) vs 46 (59.7%), p=0.01]. Lymph node harvest was higher in the preconditioned cohort (p<0.01), although there was no significant difference in DFS or OS when adjusted for age, pre-operative stage, # of lymph nodes harvested, or resection status (p=0.29).
Conclusions: LIP followed by esophagectomy can be conducted safely and results in a decreased rate of strictures compared to a one-staged esophagectomy in patients with esophageal cancer.
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