title: Video. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy.
abstract: BACKGROUND
  Total minimally invasive oesophagectomy (MIO) is a valid alternative to open surgery for the management of oesophagogastric cancer and may lead to a more rapid restoration of health-related quality of life post surgery. However, a high incidence of gastric conduit failure (GCF) has also been observed which could be detrimental to any potential benefits of this approach. Technical modifications have been introduced in an attempt to reduce conduit morbidity, and the aim of this study was to evaluate their efficacy.
  
  
  METHODS
  Minimally invasive oesophagectomy has been the procedure of choice in our unit since April 2004. Data on patient and surgical variables are entered onto a prospective database. Laparoscopic ischaemic conditioning (LIC) by ligation of the left gastric vessels 2 weeks prior to MIO was introduced in April 2006. Extracorporeal formation of the gastric conduit through a minilaparotomy was offered to patients since January 2008. Where present, GCF was characterised as one of three types: I, simple anastomotic leak; II, conduit tip necrosis; and III, whole conduit necrosis.
  
  
  RESULTS
  As of January 2010, 131 patients had undergone an MIO and GCF was observed in 21 patients (16.0%). Sixty-seven patients had LIC and 9 of them (13.4%) developed GCF (I, 10.4%; II, 0%; III, 3.0%) compared to 12 (18.8%) of 64 patients who did not have LIC (I, 6.3%; II, 7.8%; III, 4.7%). A total of 43 patients had an extracorporeally fashioned conduit and 6 (14.0%) developed GCF (I, 11.6%; II, 0%; III, 2.3%), whilst 88 had an intracorporeal conduit with 15 (17.0%) developing GCF (I, 6.8%; II, 5.7%; III, 4.5%). GCF can be reduced with the incorporation of LIC and an extracorporeally fashioned conduit, with possible elimination of type II conduit tip necrosis.
  
  
  CONCLUSIONS
  Surgical modification of a three-stage minimally invasive oesophagectomy technique, with the further incorporation of laparoscopic ischaemic conditioning and extracorporeal conduit formation, reduces gastric conduit morbidity, allowing the potential benefits of this approach to be realised.
authors.affiliation: Department of Upper Gastro-Intestinal Surgery, Exeter Oesophago-Gastric Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW, UK. saj.wajed@rdeft.nhs.uk
authors.forename: Shahjehan A
authors.initials: SA
authors.lastname: Wajed
authors.forename: Darmarajah
authors.initials: D
authors.lastname: Veeramootoo
authors.forename: Angela C
authors.initials: AC
authors.lastname: Shore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D006801:Humans; D019194:Ischemic Preconditioning / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011475:Prosthesis Failure; D012189:Retrospective Studies; D013270:Stomach / Q000098:blood supply / Q000601:surgery*; D054047:Surgical Stomas / Q000098:blood supply*