Gastric Ischemic Conditioning Prior to Esophagectomy Is Associated
with Decreased Stricture Rate and Overall Anastomotic Complications
Steve R. Siegal
Abhishek D. Parmar
Kelly R. Haisley
Brandon H. Tieu
Paul H. Schipper
John G. Hunter
James P. Dolan
Received: 20 November 2017 /Accepted: 15 May 2018
2018 The Society for Surgery of the Alimentary Tract
Background Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior
studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association
between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients.
Methods We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer
Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular
disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of
the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic
complications. Secondary outcomes were overall morbidity.
Results Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients
(18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology,
and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced
anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3
vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p =0.03).
Conclusions Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less
morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic
Keywords Ischemic conditioning
The incidence of esophageal cancer is increasing worldwide,
with nearly half a million incident cases in 2008 alone.
USA, adenocarcinoma of the esophagus has an estimated
overall 5-year survival no better than 15%.
outcomes for esophageal resection have steadily improved
over time with the advent of minimally invasive techniques
and improved perioperative care, surgeons continually strive
to investigate etiologies of morbidity that can be altered to
improve postoperative outcomes.
Though the majority of
morbidity after esophagectomy is related to pulmonary com-
plications, an associated morbidity is due to anastomotic
The etiology of anastomotic complications
is likely multifactorial, though tissue ischemia of the newly
formed gastric conduit is a key factor in the development of
these feared complications.
Ischemic conditioning (IC) of the stomach was first
described almost 20 years ago and has shown improve-
ment in blood flow to the future site of anastomosis by
hypertrophy and neovascularization from the remaining
Though some published reports have
shown reduction in the incidence and severity of anas-
tomotic leaks after ischemic conditioning, these results
Presented at the Washington/Oregon Chapters of the American College of
Surgeons Annual Meeting, June 2017, Chelan, WA and the American
College of Surgeons Clinical Congress October 2017, San Diego, CA
* James P. Dolan
Department of Surgery, Oregon Health & Science University, 3181
SW Sam Jackson Park RD, Mail Code: L223A, Portland, OR 97239,
Journal of Gastrointestinal Surgery