Title:
Safe and simple gastric conduit pull-through procedure through the posterior mediastinal route using echo probe cover in thoracoscopic subtotal esophagectomy.

Abstract:
A gastric conduit is commonly used to reconstruct the alimentary tract after esophagectomy. When the posterior mediastinum is applied to a reconstruction route, the gastric conduit created has been protected by an echo probe cover and, then blindly elevated to the neck. However, using this elevation method, the gastric conduit has the potential to catch on the vessels and nerves, posing a risk of major bleeding. We report a safe method of gastric conduit pull-through procedure to avoid unexpected technical complications. Two approximately 60-cm-long polyester tapes are prepared and ligated at both ends forming a loop. A 50-cm-long echo probe cover of 10 cm in diameter is prepared, and the closed end of the echo probe cover is cut to make an open-ended echo probe cover. A line parallel to the long axis of the echo probe cover is drawn across the echo probe cover with a sterile surgical marking pen. The looped polyester tape is inserted into the echo probe cover. The looped polyester tape and echo probe cover are ligated with 2-0 silk, approximately 5 cm in front of the knots on both sides. After dissection is carried out according to practice, the previously crafted polyester tape is inserted into the chest cavity. The echo probe cover is placed to connect the distal and proximal ends of the esophagus, and its torsion is corrected using the line marked with the pen and a crease, both of which are parallel to the long axis of the echo probe cover. One end of polyester tape is fixed to the distal esophageal stump by using the clips, with the opposite end fixed to the proximal esophageal stump. Either one of the 2 lengths of polyester tape is connected to the gastric conduit. By pulling up this length of polyester tape from the neck, the gastric conduit can pass through the echo probe cover and be elevated to the neck.