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Page 6 of 11 Matto et al. Mini-invasive Surg. 2025;9:19 https://dx.doi.org/10.20517/2574-1225.2025.51

this mediastinal pleural plane inferiorly near the diaphragm, extending laterally toward the chest wall,
descending aorta, and azygous vein, forming a “U-shaped Pathway”. This exposes the distal esophagus and
proximal stomach and facilitates specimen retrieval into the chest.

Once the specimen is visible in the chest, the tip of the gastric conduit can be seen sutured to the staple line
along the lesser curvature of the stomach. We routinely suture the top of the new gastric conduit, along the
greater curvature vessels, to the specimen’s staple line near the lesser curvature vessels and associated fat. At
this point, it is essential to carefully assess the orientation of the gastric conduit as it is brought into the
chest. This helps prevent spiraling and ensures proper orientation. The surgeon should confirm that the
staple line of the neo-esophagus (gastric conduit) is facing the right thoracic cavity, while the greater
curvature and short gastric vessels are directed downward, toward the spleen. Once proper orientation is
confirmed, the suture connecting the esophagogastric specimen to the new gastric conduit is divided. A
single holding stitch is then placed at the tip of the gastric conduit to secure it to the diaphragm, thereby
maintaining correct orientation and preventing retraction into the abdominal cavity.

The esophageal dissection should extend proximally to a point where the surgeon is confident that an
adequate proximal margin will be achieved. It is important to consider the original tumor location prior to
any neoadjuvant therapy. We generally aim for at least a 5 cm gross margin from the proximal edge of the
tumor and/or Barrett’s esophagus to the point of esophageal transection. It is generally good practice to
have a flexible esophagoscope in place, allowing an assistant to confirm that the planned transection site will
provide the desired margin. Before finalizing the transection site, the surgeon should have already
performed an on-the-table esophagogastroduodenoscopy to view the esophagus and tumor at the beginning
of the case. Based on these findings, the surgical team should have a discussion to reach a consensus on the
optimal transection point. Before dividing the proximal esophagus, the gastric conduit should be retrieved
and the tip carefully lifted to the anticipated site of the proximal esophageal anastomosis. In most GE
junction tumors, there is usually sufficient length in the tension-free conduit to permit resection of several
centimeters of the gastric conduit tip while still reaching the proximal esophagus margin above the azygous
vein. If there is concern about conduit tension or difficulty reaching the planned transection site, several
considerations must be addressed before proceeding with esophageal division or stapling the conduit tip.

In cases of conduit tension, the surgeon should first carefully examine the orientation of the conduit and
gently draw the greater curvature fat and omentum into the thoracic cavity. The greater curvature fat,
especially when an omental pedicle flap is present, can often become trapped at the hiatus. Careful
dissection in this area can frequently release the conduit, facilitating its advancement into the chest. At this
stage, it is also important to avoid drawing excessive gastric conduit into the thoracic cavity, as this can
create a redundant segment just above the hiatus, potentially leading to dysphagia and stasis within the
conduit.

If tension-free delivery of the conduit tip remains problematic, surgical judgment becomes critical in
considering leaving more proximal esophagus. Performing an anastomosis under tension significantly
increases the risk of leakage and stenosis. Another option is to retain a longer segment of the conduit by
resecting less of its tip. Ideally, a good oncologic margin can still be achieved while removing 5 or more
centimeters of the conduit tip. This resection eliminates potentially ischemic tissue and provides additional
length at the gastric margin. A thoughtful and meticulous approach to these steps is crucial to achieving
both optimal oncologic and functional outcomes.