The history of gastric tube dates back to 1970s, when the length of “whole stomach” were not enough to reach the anastomosis in some cases, the surgeons then transversely cut and longitudinally sutured the lesser curvature to prolong the length of stomach, which might be the earliest gastric tube. However, to accurately understand the importance of gastric tube in esophagus reconstruction, not only basic theory and knowledge but also long-term life quality follow-up of the patients are needed [15]. From clinical perspective, “gastric tube” has some advantages comparing with “whole stomach”, such as reducing postoperative fistula and improving functions of the thoracic stomach (Fig. 18.2).

Despite the long-existing debate about whether “gastric tube” or “whole stomach” interposition causes a higher incidence of fistula, it is well recognized that the anastomosis fistula of gastric tube bears less morbidity and mortality. The reasons are as follows: (i) the only blood supply vessel of thoracic stomach is the right gastroepiploic artery, which offers blood for 60 % of pylorus proximal stomach, the blood supply of the other 40 % stomach at distal side of pylorus is offered by submucosal small vessels. The poorly blood-supplied gastric fundus is removed during the gastric tube procedure, and the anastomosis as close to the initial part of right gastroepiploic artery, which can prevent gastric conduit necrosis to some extent; (ii) The severity of anastomosis fistula of intrathoracic stomach is positively correlated with the amount of gastric content. During the gastric tube interposition, nearly one-half of stomach is resected, thus the acid secretion area is reduced and the severity of fistula is accordingly decreased; iii. The gastric tube formation makes the length of the lesser curvature equivalent with that of the greater curvature, thus the anastomosis and pylorus are on the same line of gravity, which solves the problem of stomach retention and emptying dysfunction, and further decreases the risk of anastomosis fistula and its severity [16].

Dyskinesia of thoracic stomach: despite the ongoing controversies in terms of “gastric tube” and fistula, the functional preservation of “gastric tube” have been generally recognized and accepted. Whole stomach interposition renders faster functional recovery of gastric movement; however, the large volume and gastric distension make it difficult for the pressure in the stomach to be higher than that in the pylorus, which could easily lead to gastric dilatational retention, regurgitation and emptying dysfunction. In addition, the lengthy, lack of innervations and low-tensional greater curvature is more prone to be prolapsed, which could lead to the pyloric orifice locates higher than the lowest point of stomach, and acute angles could even be formed between the longitudinal axis of stomach and pylorus, all these circumstances could easily lead to emptying dysfunction of the thoracic stomach. The formation of narrow-body gastric tube makes the length of lesser curvature equivalent with that of greater curvature, so that the anastomosis and the pylorus are on the same line of gravity. Due to the restriction of the gastric tube, the intra-gastric pressure is higher than intra-pylorus, which improves the emptying. The distortion of the gastric conduit could occur in the procedure the whole stomach pull-up; this could easily lead to emptying dysfunction. Therefore, in terms of anatomic bionics, “gastric tube” is a better analogy to “esophagus”, thus could reduce dyskinesia of thoracic stomach to the largest extent [16].

The mobilization maneuver should be gentle in order to avoid injury of the stomach fundus and further thrombus formation. Attentions should be paid to the directions in the procedure of stomach pull-up, in order to avoid twisting of thoracic stomach or blood supply vessels. Preoperative management of comorbidities such as diabetes and malnutrition, intra-operative evaluation of outlet tightness of thorax and sufficient drainage of the mediastinal interval through which the thoracic stomach is pulled up and postoperative early enternal nutrition (12 h after the operation) and avoidance of early atelectasis, hyoxemia and hypotension are all necessary to guarantee the success of gastric interposition for esophagus.

Currently, the modern double stapling technique advances include the transition from hand-sewn to staple sutures, and from silk to absorbable material of better histocompatibility. Esophagectomy include “variability” in the wisely adoption of surgical procedure, “knowledge” in the esophagectomy and “technicality” of esophageal surgical approach. The choice of esophagectomy approach should depend on patients’ condition and tumor characteristics. There is no fit-for-all esophagectomy. High volume center with experienced surgical teamwork is the guarantee.

Colon interposition should be considered for patients with a history of gastrectomy or the wide extent involvement. Comparing with right hemicolon, the lumen is usually smaller. The distance between left hemicolon and esophagus is relatively shorter, and the available bowel tube of left hemicolon is with less anatomic variation. Noteworthy, inferior mesenteric artery is susceptible to arteriosclerosis; therefore, blood supply should be carefully evaluated before the procedure. The colon interposition is more suitable for distant inter-position (cervical or upper thoracic esophagus). For instance, when left hemicolon (isoperistaltic) is chose, its blood supply vessel is inferior mesenteric artery which flow through the ascending branch of left colonic artery; when antiperistalsis bowel is chose, then its blood supply is offered by middle colonic artery; when a short segment of colon is applied, then either transverse colon and middle colonic artery or splenic flexure of colon and left colon artery can be an alternative. As to right hemicolon, due to its variation of blood supply and poor flexibility, its application is restricted under the circumstances when other alternatives are all unavailable.

The colon with stenosis, extensive diverticulosis, or cancer is not suitable to be the esophagus substitute. Additionally, a past history of abdominal procedure makes the exposure and of dissection of vessels inadequate. As inferior mesenteric vein reflow into splenic vein, patients with a history of severe pancreatitis or other conditions are more likely to suffer from splenic venous thrombosis. Under these circumstances, the application of left hemicolon interposition carries a risk of inferior mesenteric venous thrombosis.

The essentials in operation are as follows: firstly, explore left hemicolon by middle laparotomy, then dissect left hemicolon and the peritoneal ligament alongside with the Toldt white line, identify the blood supply vessel of the left hemicolon by intra-operative diascopy, and temporarily clip the middle colonic artery and palpate the pulses of marginal artery; if the pulse couldn’t be ascertained, then ultrasonic Doppler transcriber should be adopted intra-operatively to evaluate the blood flow. Only when blood supply is guaranteed can esophagectomy be performed. Ligate and dissect mesenteric artery and middle colonic artery away from Drummond marginal artery (Fig. 18.3); finally, re-anastomose the remnant colon and close the peritoneum.

Jejunum interposition for esophageal replacement is most commonly applied to substitute the distal esophagus, especially esophagus with benign diseases such as regurgitation. The methods of jejunum interposition are various, including free jejunum, pedicle jejunum or Roux-en-Y approach [17, 18] (Fig. 18.4). Usually, proximal jejunum and the first branch of jejunum branches from upper mesenteric artery is chose. The jejunum mesentery of asthenic patients is relatively longer, and sometimes it could reach the lower side of arcus aortae. The jejunum mesentery of child could even reach the cervical level of esophagus. Meanwhile, “enhanced charge”, such as intrathoracic artery-jejunum artery anastomosis should be considered when replacing the substitute esophagus by the distant jejunum. In addition, jejunum interposition for esophageal replacement requires the microsurgery double anastomosis technique for superior thyroid artery and superficial vein. Roux-en-Y method could be applied for distal esophageal cancer patients with a history of whole gastrectomy. This procedure usually harvest jejunum for 20–30 cm from the proximal side of Treitz ligament, then clarify the mesenteric arch by diascopy, clip the vascular branches and dissect them, and observe the serosal layer of jejunum for several minutes to exclude ischemia. Make a pathway or route between left colonic artery and middle colonic arteries to allow jejunum graft go through. Anastomosis should be located at distal end of upper esophagus after whole gastrectomy. The abdominal and lower thoracic esophagus has to be resected as esophagogastric junction involvement. The thoracotomy access usually between the sixth or seventh intercostals; if the length of jejunum is not long enough in the procedure of Roux-en-Y, then the previously procedure should be repeated to identify mesenteric arch and achieve the extra pedicled jejunum. The mobilization of the jejunum substitute helps to prevent the gastroesophageal reflux, but the risk of avascular necrosis and anastomotic complications may rise.

Other factors that may influence the choice of esophageal substitutes include: (1) past history of thoracotomy or laparotomy; (2) anatomic variation of the circulating blood supply vessels; (3) the physiological function changes of the substitute itself; (4) vascular anastomose techniques to improve the healing procedure of anastomosis (Fig. 18.5); (5) always of great importance – the experience of thoracic surgeons.

In conclusion, the blood supply of substitute, which comprise of arterial influx and venous efflux, is the key point during the esophageal reconstruction, regardless of the approach variation. The reliable blood supply is always the cornerstone of various anastomose.

Although surgical resection offers potential cure for esophageal cancer, its associated morbidity or mortality remain high following esophagectomy. Nowadays, with the rapid development of global economy, minimally invasive esophagectomy is world-widely favored with promising peri-operative results (Table 18.1). Therefore, it is of great importance to illustrate its tips and tricks with some useful suggestions for the green hands. In this section, the topic would be discussed into three parts: thoracic, abdominal and cervical reconstruction stage.