V-23. Double-Flap Technique for Reconstruction After Thoracoscopic/Laparoscopic or Robot Assisted Ivor-Lewis Esophagectomy for EGJ Cancer
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ID: 325739
2026
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Abstract
Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Background The selection of surgical procedures for esophagogastric junction (EGJ) cancer varies among institutions. Thoracoscopic/Laparoscopic or Robot assisted proximal gastrectomy (LPG/RPG) has been performed as a minimally invasive procedure for gastric cancer in the upper third of the stomach. However, gastroesophageal reflux disease (GERD) remains a significant concern after PG. Thus, several techniques have been reported to reduce GERD. We have performed double-flap technique (DFT) which has been reported as the most physiological anti-reflux reconstruction method. We have introduced this technique to EGJ Cancer patients as a novel intrathoracic reconstruction after Ivor-Lewis Esophagectomy. Methods Between December 2017 and Dec 2025, 17 patients underwent intrathoracic esophagogastrostomy using DFT following thoracoscopic/laparoscopic or robot assisted Ivor-Lewis Esophagectomy. Mobilization of mid-to-lower esophagus and mediastinal lymph node dissection were performed with the patient in the prone position. The patient is then repositioned to the supine position. Laparoscopic or Robot assisted proximal gastrectomy and abdominal lymphadenectomy were performed. Transhiatal anastomosis is generally performed, however, when the anastomosis needs to be created at a very high intrathoracic level, the patient is placed in the prone position and the anastomosis is performed within the thoracic cavity. The upper side of the remnant stomach is fixed to the posterior wall of the esophagus at approximately 5cm from the esophageal stump. A 3x 4cm H-shape seromuscular flap is created on the anterior wall of the gastric remnant. After esophagogastric anastomosis is performed, the seromuscular flap is closed to cover the anastomosis. Results Seventeen patients underwent this technique. The mean operation time for thoracic procedure was 71.4 (58-92) min, and abdominal procedure was 300 (255-366) min . The mean blood loss was 26.5 (0-50) ml. One anastomotic minor leakage and two anastomotic stenosis occurred in an esophagogastrostomy and it was managed conservatively. All patients did not exhibit any symptoms of reflux esophagitis without anti-acid drugs. Conclusion The intrathoracic DFT is a promising approach for preventing reflux after esophagogastrostomy following thoracoscopic/laparoscopic or robot assisted Ivor-Lewis esophagectomy for EGJ cancer. Video Description This technique is technically demanding, with achieving good surgical field is most important. Exposure of the lower mediastinum after lymph node dissection gives us good surgical field. Mobilization of mid-to-lower esophagus and mediastinal lymph node dissection were performed with the patient in the prone position. The patient is then repositioned to the supine position. Robot assisted proximal gastrectomy and abdominal lymphadenectomy were performed. Mobilization of the esophagus improves its flexibility and anastomosis becomes easier. The right and left crus of the diaphragm are resected circumferentially, and the central tendon is incised to enlarge the esophageal hiatus. A 3x 4cm H-shape seromuscular flap is created on the anterior wall of the gastric remnant while preserving the gastric mucosa. The lower side of the gastric mucosa is incised for the anastomosis. The upper side of the remnant stomach is fixed to the posterior wall of the esophagus at approximately 5cm from the esophageal stump. During esophagogastric anastomosis, the esophageal stump is fixed to the anterior side of the esophageal hiatus, and the esophagus is pulled ventrally using a retractor for better surgical field.The posterior wall anastomosis is performed between all layers of posterior wall of the esophagus and mucosa of the stomach, and anastomosis of the anterior wall is performed between all layers of the esophagus and all layers of the stomach. Finally, the seromuscular flap is closed in a Y-shape to cover the anastomosis. After completing the anastomosis, an endoscope is used to confirm the absence of leakage and stenosis.
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| Authors | Hirofumi Kawakubo, Masashi Takeuchi, Satoru Matsuda, Yuko Kitagawa |
| Journal | diseases of the esophagus : official journal of the international society for diseases of the esophagus |
| Year | 2026 |
| DOI |
10.1093/dote/doag077.423
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| Keywords | Keywords not found |
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