What is the blood supply for the conduit in an esophagectomy?

From the Guidelines

The blood supply for the conduit in an esophagectomy is primarily provided by the right gastroepiploic artery, which runs along the greater curvature of the stomach, and preservation of this artery is critical for conduit viability. The gastric conduit is the preferred choice for esophageal reconstruction following esophagectomy due to its reliable blood supply 1. This vessel provides the main blood supply to the gastric conduit after the left gastric, short gastric, and left gastroepiploic vessels are divided during mobilization.

Key Points to Consider

• The blood supply to the proximal portion of the conduit is relatively tenuous, relying on intramural vessels and the submucosal plexus, which explains why anastomotic leaks most commonly occur at this location 1.
• Alternative conduits include the colon (supplied by the middle colic artery when using the transverse colon, or the left colic artery for the left colon) and the jejunum (supplied by the jejunal branches of the superior mesenteric artery) 1.
• These alternatives are typically used when the stomach is unavailable due to previous surgery, malignancy, or other pathology 1.
• Careful preoperative assessment of vascular anatomy using CT angiography may be beneficial in patients with risk factors for vascular disease.
• Intraoperative techniques to optimize conduit blood supply include gentle handling of tissues, avoiding tension on the mesentery, and in some cases, performing vascular augmentation procedures such as microvascular anastomosis to supplement blood flow to the conduit.

Surgical Approach

The choice of surgical approach, such as Ivor Lewis esophagogastrectomy, McKeown esophagogastrectomy, or transhiatal esophagogastrectomy, does not significantly impact the blood supply to the gastric conduit 1. However, the surgical approach may affect the ease of mobilization and the risk of complications, such as anastomotic leaks or conduit necrosis.

Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) strategies, including minimally invasive Ivor Lewis esophagogastrectomy and minimally invasive McKeown esophagogastrectomy, may be associated with decreased morbidity and shorter recovery times 1. However, the blood supply to the gastric conduit remains a critical factor in the success of these procedures.

From the Research

Blood Supply for the Conduit in Esophagectomy

The blood supply for the conduit in an esophagectomy is crucial for a successful surgical outcome. The following points highlight the key aspects of blood supply for the conduit:

• The gastric conduit's blood supply is primarily based on the right gastroepiploic vessels 2.
• The right gastroepiploic artery (RGEA) is the sole arterial supply to the gastric remnant after esophagectomy 3.
• Indocyanine green (ICG) fluorescence imaging can be used to evaluate the blood supply to the reconstructed organs, including the gastric conduit 4, 5.
• ICG fluorescence imaging can help identify areas with inadequate blood supply, allowing for resection of devitalized portions of the conduit 5.
• The vascular network of the gastric wall, colonic grafts, and free jejunal grafts can be well visualized using ICG fluorescence 4.
• In cases where the right gastroepiploic artery is absent, alternative surgical plans can be made to ensure adequate blood supply to the conduit 2.
• The RGEA can be fed from the left middle colic artery (MCA) with microvascular anastomosis in cases where the celiac axis is stenosed 6.