What primarily supplies the blood to the thoracic stomach used for esophageal replacement?

Blood Supply of the Thoracic Stomach for Esophageal Replacement

The blood supply of the thoracic stomach used for esophageal replacement primarily depends on the right gastroepiploic artery (option c). This vessel serves as the critical blood supply for the gastric conduit when it is mobilized and positioned in the thoracic cavity for esophageal reconstruction.

Anatomical Considerations of Blood Supply

When the stomach is used as a conduit for esophageal replacement:

• The stomach must be completely mobilized while preserving its blood supply 1

• During gastrolysis and mobilization:

  • The left gastric artery is divided during lymph node dissection
  • The short gastric vessels are divided during mobilization
  • The right gastric and right gastroepiploic arteries must be preserved as they become critical for conduit viability 1

• After conventional gastrolysis, the blood supply of the stomach exclusively depends on:

  • The right gastric artery
  • The right gastroepiploic artery (primary blood supply) 2

Importance of Right Gastroepiploic Artery

The right gastroepiploic artery is particularly crucial because:

• It forms the primary blood supply to the gastric tube when formed along the greater curvature 1
• The gastric tube is created by dividing the stomach along the greater curvature while specifically preserving the right gastroepiploic arcade 1
• In narrow gastric tubes, the right gastroepiploic artery becomes the only feeding artery 3

Blood Supply Route and Visualization

• ICG fluorescence imaging studies have shown that in 66.7% of patients, the major blood supply route for the anastomosis is located in the greater omentum beside the splenic hilum 4
• The splenic hiatal vessels represent the major blood supply for the anastomosis in most patients 4

Clinical Implications and Complications

• Inadequate blood supply to the gastric conduit can lead to:

  • Anastomotic leakage (should not exceed 5%) 5, 1
  • Ischemic complications at the anastomotic site
  • Need for additional revascularization procedures in some cases

• The fundus of the stomach is at higher vascular risk since it depends on intraparietal capillary anastomoses between various gastric branches that may be compromised during mobilization 2

• The diameter of the gastric tube affects vascularization:

  • Narrow tubes show poorer vascularization, especially at the anastomotic site
  • Wider tubes or whole stomach show better vascularization 3

Alternative Techniques for Compromised Blood Supply

In cases where the right gastroepiploic artery cannot ensure sufficient blood supply:

• Intrathoracic revascularization techniques may be considered:

  • Anastomosing the left gastric artery with the right internal mammary artery
  • Creating a shunt with saphenous vein between subclavian and left gastric arteries 2

• Additional vascular anastomosis between short gastric vessels and vessels in the neck has shown:

  • Significant increase in tissue blood flow
  • Reduced risk of anastomotic leakage
  • Earlier resumption of oral feeding 6

While other vessels play roles in the native esophageal blood supply, the right gastroepiploic artery is the critical vessel that must be preserved when creating a gastric conduit for esophageal replacement.