Thoracoscopic Intrathoracic Double-Flap Technique for EGJC

Background: Valvuloplastic esophagogastrostomy using the double-flap technique (DFT) after proximal gastrectomy and lower esophagectomy for esophagogastric junction cancer (EGJC) is effective for reflux prevention and has a low anastomotic leakage rate, making it suitable for mediastinal reconstruction. When the transhiatal approach becomes difficult, intrathoracic reconstruction provides a safer option. Although several reports have described robot-assisted intrathoracic DFT, thoracoscopic intrathoracic DFT has been reported only in isolated cases, and its technical feasibility and reproducibility have not been evaluated as a case series. Methods: We present a consecutive six-patient case series of thoracoscopic intrathoracic DFT following laparoscopic proximal gastrectomy and lower esophagectomy. After preparation of a seromuscular flap, the remnant stomach was elevated into the thoracic cavity without torsion. The posterior esophageal wall was fixed to the flap using a single barbed suture placed in a continuous fashion with four bites, followed by 90° rotation of the esophagogastric axis to bring the anastomotic site into direct view. A full-circumference hand-sewn esophagogastrostomy using single-knot sutures was then completed, and the flap was closed. Results: All procedures were completed thoracoscopically without conversion. The median reconstruction time was 78 minutes, and no anastomosis-related complications were observed. Conclusions: This case series demonstrates the technical feasibility and reproducibility of thoracoscopic intrathoracic DFT for mediastinal esophagogastrostomy. Standardized exposure using posterior fixation and 90° rotation allows stable intracavitary suturing and supports the safe application of this valve-forming reconstruction in the thoracic cavity.