What is the vascular supply of the gastric conduit in esophagectomy?

From the Guidelines

The vascular supply of the gastric conduit in esophagectomy primarily relies on the right gastroepiploic artery (RGEA) and the preservation of the gastroepiploic arcade during surgery is essential to prevent ischemic complications. The RGEA originates from the gastroduodenal artery and runs along the greater curvature of the stomach, providing critical perfusion to the gastric conduit through its intramural vascular network, as described in the context of esophageal and esophagogastric junction cancers 1. This network includes submucosal and subserosal plexuses that allow for collateral circulation. The adequacy of this blood supply is crucial for preventing ischemic complications such as anastomotic leakage and conduit necrosis. Some key points to consider in the vascular supply of the gastric conduit include:

• The most vulnerable area of the conduit is the proximal portion (fundus), which is furthest from the RGEA source and relies on these collateral vessels, creating a watershed area at the site of the esophagogastric anastomosis.
• Careful handling of the conduit to avoid damage to these vessels is necessary.
• Intraoperative assessment of conduit perfusion using techniques such as indocyanine green angiography can help evaluate the adequacy of the vascular supply. The principles of surgery for esophageal and esophagogastric junction cancers, including the type of esophageal resection and the choice of conduit, are also important considerations 1. However, the specific details of these principles are not directly relevant to the question of the vascular supply of the gastric conduit. In general, the goal of esophagectomy is to remove the tumor and restore the patient's ability to swallow, while minimizing morbidity and mortality. The choice of conduit and the technique used for anastomosis are critical factors in achieving this goal, as discussed in guidelines for the management of oesophageal and gastric cancer 1. Overall, the vascular supply of the gastric conduit is a critical factor in the success of esophagectomy, and careful attention to the preservation of the gastroepiploic arcade and the assessment of conduit perfusion is essential to prevent ischemic complications.

From the Research

Vascular Supply of the Gastric Conduit

The vascular supply of the gastric conduit in esophagectomy is primarily based on the right gastroepiploic vessels. The preservation of these vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy 2, 3.

Key Vessels Involved

• The right gastroepiploic artery and vein are crucial for the blood supply of the gastric conduit 2, 3.
• The left gastroepiploic artery also plays a role in the vascular supply of the gastric conduit, particularly in the greater curvature 4.
• The gastric conduit can be divided into three zones according to the dominant arteries present in the greater curvature under indocyanine green (ICG) fluorescence 4.

Importance of Preserving Vascular Supply

• The loss of the right gastroepiploic vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications 2, 3.
• Preserving the whole vessel arcade of the greater curvature is essential to achieve good blood perfusion in the gastric tube 4.
• Variations in vascular supply, such as the absence of the right gastroepiploic artery, can be overcome with careful planning and surgical merits 5.

Evaluation of Gastric Conduit Perfusion

• Indocyanine green (ICG) fluorescence imaging is a useful tool to evaluate the gastric conduit perfusion during esophagectomy 6, 4.
• ICG fluorescence imaging can help identify areas of inadequate blood supply, allowing for resection of devitalized portions of the conduit 6.
• Visual assessment of the gastric conduit may underestimate perfusion, and ICG fluorescence imaging can provide a more accurate evaluation of blood supply 6.