title: Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue.
abstract: BACKGROUND
  Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis.
  
  
  METHODS
  Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified.
  
  
  RESULTS
  Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51-155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447).
  
  
  CONCLUSIONS
  In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon's experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.
authors.affiliation: Guy's and St Thomas' NHS Foundation Trust, UK.
authors.forename: L
authors.initials: L
authors.lastname: Ramage
authors.forename: J
authors.initials: J
authors.lastname: Deguara
authors.forename: A
authors.initials: A
authors.lastname: Davies
authors.forename: A
authors.initials: A
authors.lastname: Hamouda
authors.forename: K
authors.initials: K
authors.lastname: Tsigritis
authors.forename: M
authors.initials: M
authors.lastname: Forshaw
authors.forename: A J
authors.initials: AJ
authors.lastname: Botha
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology*; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology; D061646:Operative Time; D019990:Perioperative Care; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation / Q000706:statistics & numerical data; D013270:Stomach / Q000098:blood supply* / Q000473:pathology; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome