Key Points

• For anatomic and physiologic reasons, the ideal esophageal replacement may be a tube constructed from the greater curvature of the stomach and vascularized by the gastroepiploic arcade.
• In adults, either preexisting colonic disease or prior colon resection prohibits the use of a colon conduit. Infants with esophageal atresia may have an associated high imperforate anus and require reconstructive colon surgery. Anomalous arterial patterns or a poor marginal artery make colon interposition hazardous. In contrast, the stomach has an excellent arterial supply in a predictable pattern (Fig.1). The gastroepiploic arcade, which is situated peripheral to the greater curvature of the stomach and thus has a greater arc, lengthens when the gastric tube is created and straightened and does not limit the length of the conduit. The colon and jejunum, with their fan-shaped mesenteries, are longer than their vascular arcades and therefore tend to be redundant when interposed between the esophagus and stomach. In contrast to the gastroepiploic vessels, which are closely applied to the stomach, these mesenteries are subject to tension and torsion.
• Colon interposition, even if not redundant when first performed, dilates and becomes redundant years later, with attendant problems of stasis and poor emptying. This phenomenon has been noted only rarely with the gastric tube.[1]
• An earlier gastrostomy is not a contraindication to the construction of a gastric tube. In fact, it is a great advantage, because the stomach may be dilated when a large amount (1000 to 1500 mL) of a liquid diet is offered every 3 or 4 hours during waking hours. In 2 to 3 months, the stomach is so enlarged that there is abundant stomach available for esophageal replacement. If this form of reconstruction is anticipated and prior gastrostomy is required, preferably it should be performed toward the lesser curvature of the stomach. The location of the gastrostomy is of little consequence, provided that the stomach is dilated as described. Prior gastric resection or outlet obstruction is usually but not an absolute contraindication to the application of the gastric tube for esophageal reconstruction.