Successful Cervical Esophageal
laparoscopy after right thoracoscopic esophageal mobili-
Reconstruction Using Gastric
Conduit Without
Gastroepiploic Artery
Lin Ma, MD, Chengwu Liu, MD, Jiandong Mei, MD,
and Long-Qi Chen, MD, PhD
Department of Thoracic Surgery, West China Hospital, Sichuan
University, Chengdu, China
The use of the stomach as an esophageal substitute after
esophagectomy is the most commonly accepted as the
standard. The colon and supercharged pedicled jejunum
are acceptable options for esophageal reconstruction
when the stomach is unavailable. We describe a case of
esophageal cancer with a history of right hemicolectomy
scheduled McKeown esophagogastrectomy. During ce-
liac detection, the gastroepiploic artery had been resected,
and the jejunum had a relatively short mesentery. In such
a situation, we used an unconventional gastric conduit
with the right gastric artery as the sole blood supply to
complete cervical reconstruction.
(Ann Thorac Surg 2019;107:e409–10)
Ó 2019 by The Society of Thoracic Surgeons
T he use of the stomach as an esophageal substitute
after esophagectomy is the most commonly accepted
standard because of its easy access, elasticity, and
comparably ample vascular supply [1]. Both the colon and
supercharged pedicled jejunum are acceptable options
for esophageal reconstruction when the stomach is
unavailable [2]. However, in the process of performing a
McKeown esophagogastrectomy, a case of esophageal
cancer with a history of right hemicolectomy placed us in a
dilemma, as follows. The gastroepiploic artery (GEA) and
the colon had been partially resected. The jejunum had a
relative short mesentery. We used an unconventional
gastric conduit to complete the cervical reconstruction.
A 64-year-old man was admitted after 2 months of pro-
gressive dysphagia with a history of colon cancer; he
underwent laparoscopic right hemicolectomy 18 months
previous. An endoscopy was performed, which showed a
tumor at the middle thoracic esophagus. A biopsy
revealed a squamous cell carcinoma. Further contrast-
enhanced computed tomography (CT) scans showed
that the tumor was located above the inferior pulmonary
vein, and no extraesophageal invasion was present.
There was no evidence of lymphadenopathy or distant
metastasis. The tumor was therefore clinically staged as
T2N0M0 and was considered for primary resection
(minimally invasive McKeown esophagogastrectomy).
Accepted for publication Sept 21, 2018.
Address correspondence to Dr Chen, Department of Thoracic Surgery,
West China Hospital, Sichuan University, No. 37 Guoxue Alley,
Chengdu 610041, China; email: drchenlq@163.com.
Ó 2019 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
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Exploration of the abdomen was performed by
zation. Unfortunately, the GEA was not found, and the
blood supply to the stomach was the left and right gastric
arteries (GAs), the posterior gastric artery, and the short
gastric vessels. The unavailable gastric conduit was
immediately realized and alternate conduits were
considered. The colon was partially resected, and the
jejunum had a relatively short mesentery for cervical
anastomosis. Exploratory laparotomy was performed and
we found the vessel arch of lesser curvature was
compensatory tortuous and dilated due to the resection of
the GEA during laparoscopic right hemicolectomy. The
stomach was then mobilized by dividing the gastro-
hepatic omentum, including the left GAs, the posterior
gastric artery, and the short gastric vessels to base the
stomach conduit on the right GA. The resection was then
completed, and a layered end-to-side manual cervical
anastomosis between the esophagus and the whole
stomach was performed. Jejunostomy was conducted for
postoperative enteral nutritional support.
The patient received gastrointestinal decompression
and enteral nutrition support after surgery. A celiac
arteriography showed the right GA became the sole
source of blood supply to the thoracic stomach (Fig 1A)
and no anastomosis or thoracic stomach fistula was
documented by upper gastrointestinal contrast on post-
operative day 7 (Fig 1B). After liquid diet intake for 3 days,
the patient underwent chest roentgenography and was
discharged on postoperative day 10 with no complication.
Comment
In most thoracic esophageal cancer patients with a history
of gastrectomy, cervical reconstruction needs to be
performed using a long colon segment transposed on a
vascular pedicle. Patients who undergo colon interposi-
tion should prepare carefully. A preoperative evaluation
of the colon is required by either colonoscopy or barium
enema in order to detect unexpected lesions, and angi-
ography is needed to detect anatomic variation [3]. In
light of the increasing incidence of esophageal cancer in
patients with obesity and chronic reflux, many of these
patients might have had prior surgery. McKeown
esophagogastrectomy in a patient with a history of
right hemicolectomy is rare, however, and there is
no consensus on how to perform the preoperative eval-
uation. With preoperative upper gastrointestinal contrast
study, the gastric pull-up was feasible. However, the
blood supply of stomach after colectomy was not fully
understood before operation. Normally, the gastric tube
was then supplied by 3 main arteries, the right and left
GAs and the right GEA. The right GEA has been shown
to have sufficient blood supply for the gastric tube
after ligation of the other gastric arteries. Blood flow
measurements and histological analysis in experimental
studies support the conclusion that ischemic pre-
conditioning increases the perfusion of the gastric tube if
an interval of at least 2 to 3 weeks is used [4]. Cancerous,
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2018.09.068
e410 CASE REPORT MA ET AL
GEA GASTRIC CONDUIT RECONSTRUCTION
Fig 1. Celiac arteriography and
upper gastrointestinal contrast. (A)
Celiac arteriography showed common
hepatic artery (hollow arrowhead),
splenic artery (black arrowhead) and
the right gastric artery (white
arrowhead), which became the sole
source of blood supply to the thoracic
stomach. (B) Upper gastrointestinal
contrast showed there was no
anastomosis (white arrowhead) or
thoracic stomach fistula on
postoperative day 7.
atherosclerotic, or surgical involvement of the right GEA
are contraindications for transthoracic and transhiatal
esophagectomies [5]. According to the National
Comprehensive Cancer Network guideline for colon
cancer, whether the right GEA needs to be resected
during lymphadenectomy (D2 dissection) has not been
clarified, and a related randomized controlled trial is
currently being conducted [6]. We suggest that either
abdominal CT angiogram or celiac angiography should
be performed prior to the operation if McKeown esoph-
agogastrectomy has been scheduled on a patient with a
history of hemicolectomy. Procedures involving a gastric
tube or the whole stomach have become widely accepted
as standard for esophageal carcinoma. Cervical recon-
struction using gastric conduit by sole right GA supply
was not reported. Prolonged vessel arch of lesser curva-
ture is regarded as the compensatory mechanism of the
ischemia of greater curvature after GEA resection. To
reserve the vessel arch of lesser curvature, we used the
whole stomach to substitute gastric tube and performed
manual anastomosis on the top of it to reduce the tension.
Gastric conduit based solely on the right gastric arterial
supply is feasible in the absence of the right GEA and
compensatory prominence of the right gastric arcade.
Sufficient preoperative assessment must be performed,
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Ann Thorac Surg
2019;107:e409–10
including length (by upper gastrointestinal contrast),
blood supply (by abdominal CT angiogram or celiac
angiography), and celiac exploration prior to surgery, in
patients with a history of abdominal surgery.
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