title: Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy.
abstract: BACKGROUND
  Minimally invasive esophagectomy (MIO) is now established as a valid alternative to open surgery for the management of esophagogastric cancers. However, a high incidence of ischemia-related gastric conduit failure (ICF) is observed, which is detrimental to any potential benefits of this approach.
  
  
  METHODS
  Since April 2004, MIO has been the procedure of choice for esophagogastric resection in the authors' unit. Data relating to the surgical technique were collected, with a focus on ischemic conditioning by laparoscopic ligation of the left gastric artery (LIC) 2 weeks or 5 days before resection.
  
  
  RESULTS
  A total of 97 patients underwent a planned MIO. Four in-patient deaths (4.1%) occurred, none of which were conduit related, and overall, 20 patients experienced ICF (20.6%). In four patients, ICF was recognized and dealt with at the initial surgery. The remaining 16 patients experienced this complication postoperatively, with 9 (9.3%) of them requiring further surgery. Of the 97 patients, 55 did not undergo ischemic conditioning, and conduit failure was observed in 11 (20%). Thirty-five patients had LIC at 2 weeks, and 2 (5.7%) experienced ICF. All seven patients (100%) who had LIC at 5 days experienced ICF. Timing of ischemic conditioning (p < 0.0001) had a definite impact on the conduit failure rate, and the benefit of ischemic conditioning at 2 weeks compared with no conditioning neared significance (p = 0.07).
  
  
  CONCLUSIONS
  Ischemic failure of the gastric conduit significantly impairs recovery after MIO. Ischemic conditioning 2 weeks before surgery may reduce this complication and allow the benefits of this approach to be realized.
authors.affiliation: Department of Thoracic and Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Royal Devon and Exeter Foundation Hospital, Exeter EX2 5DW, UK. docrajv@hotmail.com
authors.forename: Darmarajah
authors.initials: D
authors.lastname: Veeramootoo
authors.forename: Angela C
authors.initials: AC
authors.lastname: Shore
authors.forename: Beverley
authors.initials: B
authors.lastname: Shields
authors.forename: Rakesh
authors.initials: R
authors.lastname: Krishnadas
authors.forename: Martin
authors.initials: M
authors.lastname: Cooper
authors.forename: Richard G
authors.initials: RG
authors.lastname: Berrisford
authors.forename: Shahjehan A
authors.initials: SA
authors.lastname: Wajed
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019194:Ischemic Preconditioning / Q000379:methods*; D010535:Laparoscopy / Q000379:methods; D008026:Ligation / Q000379:methods; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000628:therapy; D012189:Retrospective Studies; D013270:Stomach / Q000098:blood supply* / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome