Experimental model of laparoscopic gastric ischemic preconditioning prior to transhiatal esophagectomy.

BACKGROUND

Cervical esophagogastric anastomotic disruption following transhiatal esophagectomy (THE) is a significant problem. Gastric tip ischemia is a primary cause of anastomotic failure. We examined gastric tip blood flow when laparoscopic "ischemic preconditioning" was attempted by selectively ligating the short gastric (SG) vessels or both the left and short gastric (LG/SG) vessels prior to THE.

METHODS

Seventeen (25 kg) mongrel dogs underwent laparoscopy followed 3 weeks later by THE. Three groups were studied: control group = laparoscopy only, no preconditioning (n = 6); SG group = laparoscopic ligation of SG vessels only (n = 5); and LG/SG group = laparoscopic ligation of LG and SG vessels (n = 6). Tissue blood flow was assessed using the fluorescent microsphere method. The initial microsphere injections occurred prior to pneumoperitoneum and upon completion of the laparoscopy. At the second operation, transhiatal esophagectomy was performed and microsphere blood flow assessment occurred after induction of anesthesia, after mobilization of the stomach, and after completion of the cervical esophagogastric anastomosis. The animals were euthanized and regional gastric tissue was analyzed for microsphere estimates of blood flow. Differences in blood flow were evaluated using Student's t test.

RESULTS

The mean baseline gastric blood flow was 0.58 ml/min/g. After THE, the proximal gastric blood flow fell to 16% of baseline in control and 22% in SG, but was reduced to only 60% of baseline in LG/SG. This relative preservation of blood flow among the LG/SG group approached significance compared with the laparoscopy-only (control) group (P = 0.07). Ligation of SG vessels alone provided no preservation of proximal gastric blood flow following THE.

CONCLUSION

Preoperative "ischemic preconditioning" through ligation of both the short and left gastric vessels may achieve preservation of blood flow to the gastric tip. Preconditioning during laparoscopic staging of esophageal carcinoma may be considered to reduce anastomotic complications following esophagectomy.