Gastric ischemic conditioning before esophagectomy: contemporary practices and insights from an international survey

Background: Gastric ischemic conditioning (GIC) before esophagectomy has been proposed to enhance the vascular submucosal network of the gastric conduit and perfusion at the anastomotic site. Its advantages remain controversial due to inconsistent literature findings, often attributed to heterogeneity in patient selection, targeted vessels, timing, and variations in GIC technique. We conducted a survey to assess contemporary surgical practices regarding GIC utilization prior to esophagectomy among expert foregut surgeons. Methods: A Google-based survey was conducted in accordance with the CHERRIES checklist, developed following an extensive literature review and directed towards expert foregut surgeons. The survey comprised 39 questions covering demographic data, professional experience, surgical modalities for esophagectomy, indications, timing, and technical aspects for GIC. Results: Overall, 115 expert foregut surgeons participated in the survey (response rate 76.7%). Overall, 56.4% indicated that they do not perform GIC whereas 43.6% reported utilizing GIC before esophagectomy. Main reasons for not performing GIC included lack of supporting literature (57.1%) and no clear benefit in reducing AL rate (42.9%). Selective GIC use was most often based on celiac trunk stenosis or calcification (67.7%), history of coronary stenting/bypass (48.4%), and thoracic aorta calcification (41.9%). Overall, 59.6% of experts using GIC preferred laparoscopy while 40.4% favored embolization. Laparoscopy was preferred for cancer staging, jejunostomy formation, and hospital availability; embolization was preferred for its simplicity, avoidance of general anesthesia, absence of adhesions, and ability to dynamically assess the vascular anatomy intraprocedural. The left gastric artery was the most frequently targeted vessel (> 90%) for both laparoscopy and embolization, either individually or in combination with the short gastric vessels or the left gastroepiploic artery. Almost 70% of GIC users indicated a preference for performing GIC ≥ 14 days before esophagectomy. Conclusions: The survey indicates that less than half of the experts support GIC prior to esophagectomy, preferring its selective application. Laparoscopy is preferred over embolization, likely due to better tumor staging and greater hospital availability. Most respondents also prefer GIC to be performed more than 14 days before esophagectomy.