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Comparison of Laparoscopic Gastric Preconditioning Techniques Prior to Esophagectomy: Outcomes From 81 Consecutive Cases
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: Laparoscopic gastric ischemic preconditioning (LIP) has been shown to be safe and is increasingly performed in an effort to decrease anastomotic complications following esophagectomy. However, techniques can vary widely between institutions. We present our experience of 81 cases comparing outcomes after a 2-stage esophagectomy in patients preconditioned with one of two techniques.
Methods: A retrospective review identified 85 patients who underwent LIP, of which 81 made it to esophagectomy between 10/08 - 10/15. LIP, consisting of left and short gastric artery ligation, celiac node dissection, mediastinal dissection, pyloric botox injection and jejunostomy tube (J-tube) placement, was performed in 33 patients (Type 1 LIP). Forty-eight patients were preconditioned as above except with no mediastinal dissection or J-tube insertion performed during the procedure (Type 2 LIP). Median follow-up was 16.7 months and 9.8 months for Type 1 and Type 2, respectively.
Results: Two-staged esophagectomy was completed in 81 preconditioned patients. Mean age was 61±8 vrs 62±10 yrs (p=0.81), with 80% vs 84% males (p=0.30) in Type 1 vs Type 2, respectively. Median hospital length of stay (LOS) after LIP was longer in Type 1 [2(1,2) vs 1 (1,1) days, p<0.01]. While there was no difference in LOS following esophagectomy (median 8 d, p=0.42), combined LOS for staged procedures was significantly less in the Type 2 group [11(10,14) vs. 9(8,12) days, p=0.02]. Mean time interval between preconditioning and esophagectomy was 6.7±1.4 d in Type 1 and 7.9±1.6 d in Type 2 (p<0.01). Operative time for LIP was significantly less for Type 2 [149.3±58.1 vs. 82.6±54.4 minutes, p<0.01], but subsequent esophagectomy was longer in these patients [165.5.2±76.2 vs. 260.4±81.1 minutes, p<0.01]. However, total staged operative times were not significantly different [310.1±106.7 vs. 341.3±90.0 minutes, p=0.22]. Total complications were similar between groups [68.6% in Type 1 vs. 58.0% in Type 2, p=0.64]. No difference was seen in the number of anastomotic leaks, delayed gastric emptying, or strictures, but Type 2 resulted in lower rates of complications requiring re-operation [33% vs. 15%, p=0.02]. 30-day mortality was similar between groups (3% vs 2%, p=0.99). Patients preconditioned with Type 1 vs Type 2 LIP had significantly shorter disease free survival (DFS) (log-rank p=0.02) and overall survival (OS) (log-rank p<0.01). After adjusting for group differences, survival was not significantly lowered in Type 1 patients (DFS HR=2.05 (95% CI: 0.76, 5.51), p=0.16; OS HR=2.51 (95% CI: 0.89, 7.09), p=0.08).
Conclusions: In patients undergoing LIP, a more conservative approach results in decreased rates of complications requiring re-operation without an effect on DFS or OS. These results support the use of a conservative LIP technique in patients undergoing 2-staged esophagectomy.
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