Perfusion of the gastric conduit during esophagectomy

In esophageal cancer surgery, perfusion of the gastric conduit is a critical issue. Measurement of gastric intramucosal pH (pHi) is a method to identify anaerobic metabolism as a sign of impaired perfusion. In this study we aimed to monitor changes in the perfusion of the gastric conduit at key steps during and after esophagectomy. pHi was measured per- and postoperatively using intermittent gastric tonometry in 32 patients undergoing open, 65%, or video- assisted thoracoscopic esophagectomy for esophageal cancer. Measurements focused on the surgical steps when the vascular supply to the gastric conduit was altered. A tonometry catheter was successfully placed in all patients and a decrease in pHi (mean +/- SD) was observed from baseline to after the division of the short gastric vessels (7.33 +/- 0.07 to 7.29 +/- 0.07, P = 0.005). A further reduction after the ligation of the left gastric artery (7.26 +/- 0.08, P < 0.001) and after final linear stapling the gastric conduit (7.15 +/- 0.13, P < 0.001) was observed. Two hours after surgery, pHi increased (7.24 +/- 0.09, P = 0.002). In contrast to open surgery, a trend towards less reduction in pHi was seen in thoracoscopic surgery. Patients with anastomotic leaks had lower pHi on the first postoperative day (7.12 +/- 0.05 vs. 7.27 +/- 0.08, P = 0.040). It can be concluded that each surgical step altering the vascular supply to the gastric conduit resulted in detectable changes, however transient, in pHi. Patients with low pHi on the first postoperative day were more prone to have clinically relevant anastomotic leaks.