A Novel Technique to Improve Anastomotic Perfusion Prior to Esophageal Surgery: Hybrid Ischemic Preconditioning of the Stomach. Preclinical Efficacy Proof in a Porcine Survival Model

• Main Authors: Manuel Barberio, Eric Felli, Raoul Pop, Margherita Pizzicannella, Bernard Geny, Veronique Lindner, Andrea Baiocchini, Boris Jansen-Winkeln, Yusef Moulla, Vincent Agnus, Jacques Marescaux, Ines Gockel, Michele Diana
• Format: Article
• Language: English
• Published: MDPI AG 2020-10-01
• Series: Cancers
• Subjects: esophageal cancer; esophageal resection; Ivor-Lewis procedure; optical imaging; anastomotic leak; hyperspectral imaging
• Online Access: https://www.mdpi.com/2072-6694/12/10/2977
• ISSN: 2072-6694

Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (<i>n</i> = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA); (2) Min-IGP (<i>n</i> = 5): LGA-embolization, SGA-LapD; (3) Sham (<i>n</i> = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO₂) by hyperspectral-imaging; (B) Serosal time-to-peak (TTP) by fluorescence-imaging; (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO₂ and FCD-A index (41 ± 10.6%; 0.03 ± 0.03 respectively) than min-IGP (66.2 ± 10.2%, <i>p</i>-value = 0.004; 0.22 ± 0.02, <i>p</i>-value < 0.0001 respectively) and max-IGP (63.8 ± 9.4%, <i>p</i>-value = 0.006; 0.2 ± 0.02, <i>p</i>-value < 0.0001 respectively). Sham had higher LCL (9.6 ± 4.8 mL/mol) than min-IGP (4 ± 3.1, <i>p</i>-value = 0.04) and max-IGP (3.4 ± 1.5, <i>p</i>-value = 0.02). For StO₂, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 ± 4.9 s) than max-IGP (10 ± 1.5 s, <i>p</i>-value = 0.0008) and min-IGP (14 ± 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.