The arterial blood supply to the stomach was covered in Chapter 18 . The blood supply for the distal esophagus is derived from perforating arterial branches from the aorta. Extensive mobilization of the distal esophagus may interrupt these arteries and compromise the arterial blood supply.

The vagus nerves run parallel to the distal esophagus. The right vagus nerve trunk can be spared during esophageal transaction in order to preserve branches to the gallbladder.

In patients who are scheduled for total gastrectomy, the proximal extent of disease is critical to determine whether a distal esophagectomy should be performed. Preoperative endoscopy images should be carefully reviewed, including a phone conversation with the referring gastroenterologist or surgeon. Imaging studies such as CT scans and PETs may be helpful in identifying extent of metastases as well.

Tumors of the gastroesophageal junction usually require distal esophagectomy, which can be performed via a left thoracoabdominal, abdominal right thoracic (Ivor Lewis), or transhiatal approach. Patients who present with gastroesophageal junction tumors should be carefully assessed prior to scheduling for any surgical procedure.

Anesthesiologists should be aware of the possible need for extension of incisions into the thoracic cavities. In the event that this is necessary, a dual lumen endotracheal tube and single lung ventilation may be necessary during a portion of the operative procedure.

Intraoperative endoscopy and diagnostic laparoscopy may be helpful in confirming the extent of disease. The right and left chest should be prepped in the operative field in case an extension of the incision is necessary. The proximal stomach and distal esophagus can be accessed via midline laparotomy or bilateral subcostal incisions with a vertical extension. Self-retaining retractors are again helpful in providing exposure.

As with any upper abdominal surgery, early mobilization of the patient and agressive pulmonary toilet should be instituted. Adequate pain control via epidural catheter, subcutaneous local anesthesia catheter, or patient-controlled anesthestic devices will assist in recovery.

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  Early intestinal feedings and nutritional support are preferred even after the patient starts oral feedings. It is likely that patients will have to alter their eating habits with small frequent meals following subtotal gastrectomy.

  
  
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  Upper gastrointestinal studies to check for anastomotic integrity are not essential but can be helpful, particularly if patients exhibit unexpected fever, abdominal pain, flank pain, or shoulder pain in the early postoperative period.