What vessels are ligated during an esophagectomy (esophagus removal)?

From the Guidelines

During an esophagectomy, the left gastric artery and vein, short gastric vessels, and branches of the azygos vein are typically ligated to safely remove the esophagus. The left gastric artery is particularly important as it serves as the primary blood supply to the lesser curvature of the stomach and lower esophagus 1. The right gastric and right gastroepiploic vessels are typically preserved to maintain blood supply to the gastric conduit that will replace the esophagus. In thoracic approaches, branches of the azygos vein that drain the esophagus are ligated, while in transhiatal approaches, direct venous branches to the esophagus are addressed 1. The thoracic duct may also require ligation, especially if damaged during the procedure, to prevent chylothorax. The specific vessels ligated may vary depending on the surgical approach (transthoracic, transhiatal, or minimally invasive) and the extent of lymph node dissection required for oncologic purposes 1. Proper vessel ligation is crucial to minimize bleeding complications while preserving adequate blood supply to the remaining tissues used for reconstruction. Some studies suggest that minimally invasive esophagectomy (MIE) strategies may be associated with decreased morbidity and shorter recovery times 1, but the choice of surgical approach ultimately depends on the individual patient's needs and the surgeon's expertise. It is essential to prioritize the patient's safety and well-being, considering factors such as morbidity, mortality, and quality of life when making decisions about esophagectomy. Key considerations include:

• The type of esophageal resection and the location of the tumor
• The available choices for conduit and the surgeon's experience
• The patient's overall health and ability to undergo surgery
• The potential risks and benefits of different surgical approaches. By carefully evaluating these factors and prioritizing the patient's needs, healthcare providers can make informed decisions about esophagectomy and provide the best possible outcomes for patients with esophageal cancer.

From the Research

Vessels Ligated in Esophagectomy

• The left gastric vessels are ligated in an esophagectomy, as described in a study on preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy 2.
• The azygos vein is also resected as part of the en-bloc esophagectomy in patients with esophageal cancer, with a study showing that lymph nodes metastases along the azygos vein are too frequent to neglect their existence 3.
• Other vessels that may be ligated or resected during an esophagectomy include:
  • Accessory left hepatic artery arising from the left gastric artery 4
  • Replaced type left hepatic artery 4
  • Replaced right hepatic artery branching from the superior mesenteric artery 4
  • Accessory posterior gastric artery 4
  • Abnormalities of the splenic and subphrenic arteries 4

Rationale for Ligation

• Ligation of the left gastric vessels is done to improve collateral blood flow of the gastric conduit and reduce the frequency of anastomotic dehiscence after esophagectomy 2.
• Resection of the azygos vein is done to ensure nodal clearance and remove potential lymph node metastases 3.