Studies have demonstrated that use of a gastric conduit, as opposed to jejunal or colonic, for esophageal replacement following esophagectomy is associated with similar, if not lower, rates of ischemia. However, this highly morbid complication still occurs with use of stomach, with estimates ranging from 0.5% to 10.4% of cases [7–9]. Research has shown that mobilization of the gastric fundus during esophagectomy is associated with a greater than 50 % decrease in gastric tissue oxygen tension and that this resulting degree of oxygenation is correlated with subsequent success of the esophagogastric anastomosis [10, 11]. Consequently, while some loss of tissue perfusion and oxygenation is unavoidable during this surgery, optimizing conditions for blood flow is critical for a successful anastomosis and good postoperative outcomes. These studies highlight the importance of careful, gentle manipulation and handling of the whole gastric conduit throughout the entirety of the operation to minimize local trauma, vascular torsion/kinking, or conduit tension or compression. From a physiologic perspective, it is also important to avoid worsening perioperative splanchnic hypoperfusion by minimizing the use of vasopressors and alpha agonists. Communication with the anesthesia team intraoperatively and critical care team postoperatively regarding the significance of avoiding these medications is key to maximizing oxygen tension in the newly mobilized gastric conduit.

A detailed past medical and surgical history is critically important prior to esophagectomy. Known aorto-iliac occlusive disease or peripheral vascular disease, as well as any prior vascular intervention whether transabdominal or catheter-based, should raise concern for adequacy of gastric conduit perfusion after mobilization. An associated history of diabetes, given its known impact on both macro and microvascular disease, may also warrant a more focused evaluation. A dedicated computed tomography (CT) scan of the chest, abdomen, and pelvis is often part of the preoperative evaluation of the esophageal cancer patient. In addition to reviewing the tumor and nodal morphology and ruling out metastases, the surgeon should also evaluate the visceral aorta for extensive calcification. In the setting of the aforementioned comorbid conditions, evaluation of celiac and mesenteric arterial integrity may be achieved through modalities such as CT or magnetic resonance (MR) angiography or aortography.

Currently, patients who have a planned esophagectomy, do not routinely undergo any form of preoperative screening to ensure an appropriate diameter or size of the RGEA. Evidence from cardiac surgery has shown that preoperative evaluation of this vessel in the form of transabdominal ultrasound or multidetector CT is feasible and may be worthwhile in operative planning for coronary artery bypass revascularization [12, 13]. For example, in a study by Minakawa et al., the authors used preoperative sonography to evaluate the RGEA and identify patients with a threshold artery diameter of 2 mm for subsequent revascularization. All individuals that met this criterion preoperatively were found intraoperatively to have arteries sizeable enough for subsequent anastomosis. Furthermore, comparison of preoperative ultrasound measurements with postoperative angiography of this vessel was highly correlated and confirmed acceptability of this screening approach. Unfortunately, data regarding the use of preoperative evaluation of the RGEA in esophagectomy are lacking. However, in patients who may have a history of foregut surgery, previous exploratory laparotomy, prior cardiac surgery with an unknown graft, or aberrant or incomplete anatomic visualization on routine preoperative imaging, the use of either of these modalities with special attention to the RGEA may prove useful in operative planning.

Given the infrequency with which dedicated imaging of the RGEA is obtained preoperatively, it is important that soon after entering the peritoneal cavity and establishing exposure that the RGEA is identified. There is tremendous known variability in the celiac and hepatic arterial system and thus the location and path of the RGEA [14]. While this vessel reliably originates just inferior to the pylorus and traverses along the greater curvature, its relationship with the LGEA is subject to change as described above [1]. As such, to avoid accidental injury, it is advantageous to locate and establish the RGEA’s anatomic relationship and path early upon entering the abdomen prior to proceeding further in the course of the operation. This is especially true during any abdominal reoperation as adhesions may distort or obscure the precise anatomy of the omentum, transverse colon, and greater curvature of the stomach.

During the preparation of the gastric conduit, the greater omentum is separated from the greater curvature of the stomach. At this point in the operation, the surgeon should be extremely mindful of the previously identified course of the RGEA. Accidental injury, or excessive manipulation, of this vessel during dissection of the omentum can cause irreparable vascular compromise and subsequently result in an inability to use the stomach as a conduit for esophageal replacement [15]. Consequently, it is recommended that a minimum of 2.0 cm clearance be given between the RGEA and the omentum to be divided to avoid accidental mechanical or thermal injury (Fig. 9.2 ) [16]. Additionally, particular attention should be given when the dissection approaches the pylorus as the RGEA courses deep and posterior to the duodenal bulb to its origin from the gastroduodenal artery. The gastrocolic ligament and omentum are often fused with the transverse mesocolon in this location. Careful separation of these planes is required to avoid traction injury to the RGEA or its accompanying veins. This dissection also promotes easier passage of the conduit cephalad while decreasing subsequent anastomotic tension.

Esophagectomy with the use of a gastric conduit involves a delicate balance of obtaining appropriate reach of the conduit while preserving vascularity to the esophagogastric anastomosis. Ensuring an appropriate length of conduit is key not only for achieving a tension-free anastomosis but also for minimizing reflux in the patient postoperatively [15]. Transferring of the conduit cephalad into the chest or neck is a critical step in the course of the operation. During this time, it is important to avoid excessive stretch, torqueing, or twisting that may result in stenosis, dissection, or a traction injury to the RGEA. Maintaining collinear movement of the conduit with its vascular pedicle will help to safeguard against inappropriate twisting or rotation during mobilization.

Additionally, after the tubularized stomach has been relocated to the chest, the surgeon should inspect the conduit to ensure that there is no excessive compression at the diaphragmatic hiatus. In recognition of this, we routinely open the hiatus anteriorly to the pericardial reflection, ligating the crossing phrenic veins. Omitting these safeguarding steps may result in significant vascular compromise to the conduit with identification after it is too late. Arterial compromise typically presents early postoperatively with acidosis and evidence of a systemic inflammatory response syndrome (SIRS) due to conduit necrosis. Venous compression is more insidious with full thickness necrosis often delayed until postoperative days 5–7.