Background: Gastric conduit necrosis following esophagectomy remains a devastating complication associated with anastomotic failure and mortality. Ischemic conditioning (IC) promotes neovascularization and may reduce this risk. We describe a hybrid twostage protocol integrating laparoscopic vascular ligation with percutaneous angioembolization, timed within the neoadjuvant treatment pathway.

Methods: We performed a single-center retrospective cohort study (January 2015–December 2025) comparing 7 patients who received a hybrid two-stage IC protocol (laparoscopic short gastric vessel ligation followed by percutaneous angioembolization of the left gastric artery) with 15 non-conditioned patients who received tubular gastric conduit reconstruction. The primary outcome was the Comprehensive Complication Index (CCI®). Secondary outcomes included conduit necrosis, anastomotic leak, and 30-day mortality.

Results: Twenty-two patients with gastric conduit reconstruction were analyzed (IC, n = 7; non-IC, n = 15); five patients with nongastric reconstruction (colon interposition n = 2, Roux-en-Y esophagojejunostomy n = 3) were excluded from conduit-specific outcome analysis. Median CCI® was 8.7 versus 39.7 (p = 0.192). Conduit necrosis occurred in 0/7 (0%) versus 4/15 (26.7%), anastomotic leak in 0/7 versus 2/15 (13.3%), and 30-day mortality in 0/7 versus 2/15 (13.3%). The conditioned group demonstrated higher pCR rates (42.9% [3/7] vs 14.3% [1/7] in neoadjuvant-treated non-IC patients) and shorter ICU and hospital stays.

Conclusions: In this hypothesis-generating cohort, a hybrid two-stage laparoscopic-angioembolization IC protocol was associated with numerically lower conduit necrosis, morbidity, and mortality, without adding treatment delay. Among the five protocol-adherent cases, no conduit complications or mortality were observed. These findings support prospective multicenter evaluation.