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Introduction: Anastomotic complication is a major morbidity associated with esophagectomy. Gastric ischemia after conduit creation is believed to contribute to anastomotic complications, but we lack a reliable method to assess gastric conduit perfusion. We hypothesize that fiber optic spectroscopy (FOS) can reliably assess conduit perfusion and that the degree of intraoperative gastric ischemia will correlate with the development of anastomotic complications.Methods: FOS utilizes the differential spectral absorbance characteristics of oxy- and deoxy-hemoglobin to determine oxygen saturation (OSat) and blood volume fraction (BVF) within tissues. FOS was used to measure OSat and BVF in the distal tip of the gastric conduit at baseline, after division of the short gastric vessels, left gastric vessels, gastric tube creation, and conduit pull-up. OSat and BVF readings were normalized to baseline and correlated to clinical outcomes.Results: Between 2008 and 2009, 23 patients underwent minimally invasive esophagectomy. Four patients had ischemic conditioning by short gastric vessel division at a median of 94 days prior to esophagectomy. Seven patients developed an anastomotic leak or stricture. OSat decreased from 47.5% at baseline to 32.3% after conduit creation (p=0.002) and then to 36.4% after pull-up (p=0.02). Relative to baseline value, BVF increased by 166% after conduit creation (p=0.06) and by 256% following pull-up (p=0.02). Compared to patients without anastomotic complications, those who manifested anastomotic complications had greater intraoperative changes in OSat (18.9% decrease from baseline versus 50.2%, p=0.02). However, BVF (160.2% vs. 169.2%, p=0.9) did not differ between patients with and without anastomotic complications. Compared to patients who underwent immediate reconstruction, those who underwent ischemic conditioning had significant differences in BVF relative to baseline (182.5% versus 73.1%, p=0.02). However, OSat did not decrease significantly (29.3% decrease from baseline vs. 29.8%, p=0.9) for patients with versus those without prior ischemic conditioning after conduit creation.Conclusion: In this study, the degree of intraoperative gastric ischemia resulting from gastric conduit creation is associated with the development of anastomotic complications. In patients undergoing ischemic conditioning, decreases in BVF suggests less venous congestion in the gastric conduit. Our preliminary data indicate that FOS is useful in assessing the changes in conduit perfusion during esophagectomy. Further studies are needed to evaluate strategies to improve gastric perfusion and venous drainage during esophagectomy.