Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy

Abstract

Background: Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. Purpose: Compare short-term outcomes among different GIC techniques. Materials and Methods: Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. Results: Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47–0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31–0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12–0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65–2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. Conclusions: Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.