Positive Impact of the Double-Flap Technique for Reconstruction After Thoracoscopic/Laparoscopic or Robot Assisted Ivor-Lewis Esophagectomy for Egj Cancer

Background 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 Mobilization of mid-to-lower esophagus and mediastinal lymph node dissection were performed with the patient in the prone position under artificial pneumothorax. The patient is then repositioned to the supine position. Minimal invasive proximal gastrectomy and abdominal lymphadenectomy were performed. A 3x 4 cm 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 and anastomosis with the esophagus. The seromuscular flap is closed to cover the anastomosis. Between December 2017 and April 2024, fifteen patients under went intrathoracic DFT following minimal invasive Ivor-Lewis Esophagectomy. Results The mean operation time was 367.5 min and the mean blood loss was 28.0 mL. One patient experienced a minor anastomotic leakage which was managed conservatively. None of the patients exhibited symptoms or endoscopic findings of reflux esophagitis. 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.