Morphological and functional reconstruction of the esophago-gastric junction with a double-flap technique after laparoscopic proximal gastrectomy

Souya Nunobe, Masaru Hayami, Naoki Hiki


Background: Esophagogastrostomy is frequently used as a reconstructive method following proximal gastrectomy, and although a safe and straightforward procedure, it may sometimes be accompanied by gastric reflux. Consequently, a standard method for reconstruction after proximal gastrectomy has yet to be established.
Methods: Esophagogastrostomy with a double-door valve was performed after laparoscopic proximal gastrectomy on 50 patients in the Department of Gastroenterological Surgery at the Cancer Institute Ariake Hospital, Tokyo, Japan, from January 2013 to December 2014. This new anastomotic procedure designed to reproduce the esophago-gastric junction (EGJ) consists of two parts: (I) a hand-sewing technique to render the anastomosis soft and flexible; and (II) a double-door valve to prevent the regurgitation of gastric content.
Results: The average operation time and estimated blood loss during LAPG using the described double-door technique was 388.9±10.8 min and 89.4±15.3 mL, respectively. None of the patients required conversion to open surgery, and no anastomotic leakage occurred in this study. Only one patient (2%) developed postoperative reflux-esophagitis exceeding grade B by the Los Angeles Classification, while two patients (4%) who developed stenosis of the esophagogastric anastomosis needed endoscopic balloon dilatation of an anastomotic stricture, 3 and 8 months after surgery, respectively.
Conclusions: The double-flap technique after laparoscopic proximal gastrectomy was safely and feasibly performed although long operation time. Future studies are now warranted to evaluate long-term quality of life following this procedure.