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Copyright ©The Author(s) 2019.
World J Gastrointest Surg. Mar 27, 2019; 11(3): 155-168
Published online Mar 27, 2019. doi: 10.4240/wjgs.v11.i3.155
Table 1 The Esophageal Complications Consensus Group definition and classification of conduit necrosis and ischemia[8]
TypeDiagnosisTreatment
Type I: Conduit necrosis focalIdentified endoscopicallyAdditional monitoring or non-surgical therapy
Type II: Conduit necrosis focalIdentified endoscopically and not associated with free anastomotic or conduit leakSurgical therapy not involving esophageal diversion
Type III: Conduit necrosis; extensiveIdentified endoscopicallyTreated with conduit resection with diversion
Table 2 Endoscopic classification system for the findings of gastric conduit ischaemia and necrosis[12]
GradesFindings
Grade 1Dusky bluish-color mucosa around the anastomosis covered with tenacious metallatic-appearing mucous that cannot be easily washout off
Grade 2Partial disruption of the anastomosis with equivocal viability of the adjacent mucosa or the normal pink mucosa margins
Grade 3Complete circumferential breakdown of the anastomosis with normal pink mucosa margins
Grade 4Completely necrotic black mucosa throughout the gastric conduit with the anastomosis still intact
Table 3 Risk factors for gastric conduit necrosis
Patient factorsTechnical FactorsPost-operative factors
Peripheral arterial diseaseTwists in the gastric conduitPost-operative hypotension and shock
Ischaemic heart diseaseTight hiatusVasoconstrictor use
Stenosis of the Coeliac trunk and Aorta[27]Injury to the gastro-epiploic vessels
Cardiac failure/ impaired ejection fractionMinimal access procedures[21]
DiabetesTacking sutures to the pre-vertebral fascia during transhiatal esophagectomy[22]
Tight thoracic inlet when a neck anastomosis is performed
Narrow gastric conduit
Table 4 Published Series of gastric ischaemic pre-conditioning prior to oesophagectomy in humans
Ref.CountryStudy designPatient (n)Days prior to resectionTechniqueResults
Akiyama et al[39], 1998JapanRetrospective5114Preoperative embolization of left gastric, right gastric, and splenic arteryPET is a safe procedure that contributes to the decrease in the frequency of anastomotic dehiscence after esophageal operation
Isomura et al[43], 1999JapanRetrospective3714Preoperative embolization of left gastric, right gastric, and splenic arteryReduction of postoperative anastomotic leakage in esophageal reconstruction
Nguyen et al[40], 2006United StatesRetrospective912 ± 10Ligation of left gastric vesselsThere were no anastomotic leaks in the 9 patients
Veeramootoo et al[38], 2012United KingdomRandomized controlled trial1614Ligation of left gastric vesselsLaparoscopic ischemic conditioning does not translate into an improved perfusion of the gastric conduit tip
Wajed et al[37], 2012United KingdomRetrospective6714Ligation of left gastric vessels9 of them (13.4%) developed gastric conduit failure
Bludau et al[42], 2010GermanyProspective194-5Ligation of short gastric arteries and left gastric arteryIschemic conditioning improves Mucosal oxygen saturation in the anastomotic region at the time of reconstruction
Holscher et al[41], 2007GermanyRetrospective833-7Laparoscopic gastric devascularisation preserving right gastroepiploic arcadeFeasible and safe technique that may contribute to the reduction of postoperative morbidity and mortality after esophagectomy
Table 5 Clinical studies for the evaluation of ischemic gastric conditioning using indocyanine green fluorescence imaging
Ref.YearPatient (n)Imaging systemDose ofICGStudy designConclusions
Kitagawa et al[47]201772PDE2.5 mgRetrospectiveIntraoperative ICG assessment of the gastric tube was associated with postoperative endoscopic assessment grading of anastomosis during ER
Ohi et al[51]2017120PDE2.5 mgRetrospectiveICG fluorescein imaging might decrease the incidence of anastomotic leak following ER
Koyanagi et al[48]201640PDE2.5 or 1.25 mgProspective cohortICG fluorescence is a useful means to predict the risk of anastomotic leakage after ER
Yukaya et al[55]201527Hyper Eye Medical System0.1 mgProspective cohortICG fluorescence can be used to quantitatively measure arterial blood flow and venous return of the reconstructed gastric tube in patients undergoing ER
Zehetner et al[56]2015150SPY Imaging System (Novadaq)2.5 mgProspective cohortThe use of laser-assisted fluorescent-dye angiography (LAA) may contribute to reduced anastomotic morbidity
Sarkariaet al[53]201430NIFI technology10 mgProspective cohortICG fluorescence may be a useful adjunct during MIE gastric mobilization, especially early in the learning curve for these operations
Rino et al[52]201433PDE2.5 mgProspective cohortICG fluorescence can be used to evaluate the blood supply to the reconstructed stomach in patients undergoing ER for esophageal cancer
Kumagai et al[49]201420PDENAProspective cohortICG fluorescence method has potential usefulness for evaluation of blood flow in the gastric tube during ER
Pachecoet al[46]201311SPY Imaging System (Novadaq)NARetrospectiveICG fluorescence might be useful in patients undergoing ER
Murawaet al[50]201215PDE2.5 mgProspective cohortICG fluorescence imaging allows for intraoperative modifications, but patient’s comorbidities and general health may also increase the risk of anastomosis leakage
Shimad et al[54]201140PDE2.5 mgProspective cohortThe microcirculation detected by ICG fluorescence did not necessarily provide appropriate blood supply for a viable anastomosis