Gastric conduit interposition with Roux-en-Y anastomotic technique in patients requiring concurrent esophagectomy and distal gastrectomy: experience from Shanghai Chest Hospital

Introduction

Traditionally, gastric conduit is the preferred esophageal substitute in the setting of esophagectomy due to its easy preparation. However, when concomitant esophageal disease and stomach lesions are encountered, the procedure for restoring the continuity of the digestive tract is a challenging issue in terms of selection of esophageal substitute such as colonic or jejunal graft (1,2). Given the complexity of the procedure using these latter grafts, researchers have always been investigating the availability of other alternatives to these traditional ones.

The most usually studied alternative to colonic or jejunal graft was remnant stomach. When diseases involve both lower third thoracic esophagus and gastric antrum, following both esophagectomy and distal gastrectomy, the remnant stomach with left gastric vessels preserved to maintain blood supply was able to be used as gastric conduit (3). In addition, right gastroepiploic vessels (RGEVs) can be used to provide blood supply for the remnant gastric conduit (4,5). In these studies, all gastroesophageal anastomoses resided in thoracic cavity, namely Ivor-Lewis approach. With respect to the feasibility of remnant gastric conduit in McKeown approach, to our best knowledge, there is no relevant report available in the literature.

In this surgical technique report, we presented four cases receiving both esophagectomy and distal partial gastrectomy with remnant stomach as esophageal substitute for cervical gastroesophageal anastomosis, which is fed by the preserved gastroepiploic vessel. We believe this technique would enrich the toolbox in treatment modalities for select patients requiring cervical anastomosis. We present this article in accordance with the SUPER reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-32/rc).

Methods

Patients

Between March and December 2024, four patients underwent gastric conduit interposition with Roux-en-Y anastomotic technique for concomitant esophageal and gastric diseases in Shanghai Chest Hospital. Three patients were diagnosed with synchronous middle third esophageal cancer and gastric cancer (Figure 1A). The fourth patient presented with dysphagia and vomiting after ingesting hydrogen peroxide, and preoperative work-up revealed concomitant stenosis of the lower third esophagus and pylorus (Figure 1B). Prior to surgery, Case 1 and Case 2 received two cycles of immunochemotherapy every 21 days [albumin-bound paclitaxel 338 mg, carboplatin (CBP) 410 mg, and tislelizumab 200 mg on day 1]. The clinicopathological characteristics are presented in Table 1. This study was approved by the Institutional Review Board at Shanghai Chest Hospital (No. IS24191). Written informed consent was obtained from the patients for the publication of this manuscript, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Schematic of disease distribution. (A) Case 1–3, esophageal disease in middle third esophagus and gastric lesion in distal one third adjacent to lesser curvature; (B) Case 4, chemical injury resulting in diffuse lesion.

Surgical management

All surgical interventions were performed by the same surgical team from Shanghai Chest Hospital, a tertiary-referral center. Titanium clips, which were placed via endoscopy by an endoscopist 1 day prior to the surgery, were used to facilitate intraoperative localization of small gastric lesions for Cases 1–3. Specifically, titanium clips were positioned 1–2 mm beyond the tumor edge to clearly outline the boundary of the lesion (Figure 2). One-stage esophagectomy, distal gastrectomy, and lymphadenectomy were performed as indicated (Figure 3).

Figure 2 Preoperative localization of gastric disease. Titanium clips were placed around the margin of gastric lesion via endoscopy (A) in Cases 1–3 for intraoperative localization of lesion to ensure sufficient surgical margin (B).

Figure 3 Illustration of the procedure. The schematic (A) shows the extent of resection with the dashed lines indicating the surgical margin. (B) Intraoperative surgical field. (C) Visualization of the complete procedure.

The McKeown procedure was employed for this case series. Patients were placed in a left lateral recumbent position and leaned forward 30° with artificial pneumothorax. Four thoracic ports were placed in 3^rd/6^th intercostal spaces along the right anterior axillary line and the 6^th/9^th intercostal spaces along the right midaxillary line. Esophagectomy was accompanied by lymphadenectomy in the setting of malignant disease. For the abdominal stage, the patient was placed in the reverse Trendelenburg position with the left side raised 30 degrees. Five abdominal Trocars were placed as follows: observation port (10 mm, camera) 1 cm above the umbilicus, main operation port (5 mm) at right midclavicular line 1cm below the costal margin, the second main operation port (10 mm) at midpoint between observation port and the first main operation port and the first assistant operation port (5 mm) on the left-side symmetric to the second main operation port. The second assistant operation port (5 mm) was set just below the xiphoid process. Laparoscopy-assisted mobilization of the stomach was performed. Through an upper abdominal midline incision, linear 60 mm blue staplers (Johnson & Johnson, Ethicon, Somerville, New Jersey, USA) were used to create a gastric conduit approximately 2–3 cm in width. The distal portion of the gastric conduit was resected between the duodenum and 3 cm proximal to the gastric antrum tumor, preserving the RGEV for blood supply of the remnant gastric conduit (Figure 3A). The length of the remnant gastric conduit was approximately 20–25 cm. Notably, dissection of Group 4d and Group 6 lymph nodes was typically performed via a laparotomy approach by caudally extending the second assistant operation port to 10 cm in length along the midline. Importantly, a portion of adipose tissue surrounding the RGEV must be preserved to protect it from injury, thereby ensuring the integrity of the blood supply to the gastric conduit. A pedicled jejunum graft was utilized, with the first branch vessel preserved beyond the ligament of Treitz. The third branch of the superior mesenteric artery served as the distal vascular pedicle for the mobilized jejunal conduit, while the second branch was ligated. A side-to-side anastomosis between the distal gastric conduit and the jejunum flap was scheduled using the linear 60 mm blue stapler. Jejuno-jejunostomy side-to-side anastomosis was then performed approximately 40 cm distal to the ligament of Treitz using the same stapler. Subsequently, the proximal gastric conduit was anastomosed in a side-to-end manner with the cervical esophagus using a circular stapler (Curved Intraluminal Stapler, Johnson & Johnson, Ethicon) through a retrosternal route. Then, a nasogastric tube was placed inside the gastric conduit, meanwhile a naso-jejunal feeding tube was advanced beyond the jejuno-jejunal anastomosis (Video 1).

Results

The median operation time was 390 minutes [interquartile range (IQR), 368–406 minutes], with a median intraoperative blood loss of 250 mL (IQR, 163–325 mL) (Table 1). Two patients experienced postoperative complications, namely anastomotic leakage. Notably, none of these four patients developed life-threatening complications such as graft necrosis, septic shock, re-intubation or re-operation.

Cervical anastomotic leakage occurred in Cases 2 and 3, which were conservatively managed with wound dressing twice daily and healed in 35 and 27 days, respectively. During follow-up, Case 3 developed symptomatic anastomotic stenosis and required esophageal bougienage every 4 weeks. As to the histological study for 3 patients with malignant diseases, all three were squamous cell carcinoma for esophageal disease; as for gastric disease, two were gastric cancer (Cases 1–2) and one was severe atypical hyperplasia (Case 3). The mean number of lymph nodes examined was 33±18. Pathological staging was pT1aN0 for the esophageal lesion and pT3N0 for the gastric lesion in Case 1, ypT0N0 and pT1aN0 for respective esophageal and gastric lesions in Case 2 with pT2N0 and pT1bN0 in Case 3.

The patients were followed up via outpatient visit or telephone call. Three patients are currently on a normal diet (Cases 1, 2 and 4), while Case 3, due to anastomotic stenosis, is on a liquid diet (Figure 4).

Figure 4 Follow-up esophagram. Esophagram 2 months after surgery showed patency of cervical anastomosis in Case 1 (A), Case 2 (B) and Case 4 (D) with Case 3 (C) having anastomotic stricture.

Discussion

In this case report, we demonstrated that the remnant gastric conduit is available in the McKeown approach for patients, who presented synchronous esophageal disease and gastric lesions. The preserved RGEV arcade was sufficient for the blood supply of the remnant gastric conduit. This approach offers a promising alternative to traditional colonic or jejunal substitutes and warrants further investigation in larger studies.

The remnant gastric conduit has been shown to be available in Ivor-Lewis approach among patients with concomitant esophageal and gastric malignant diseases (3-5). The intrathoracic anastomosis required shorter graft to replace esophagus resected, which also minimized the risk of anastomotic leakage (4,6,7). By contrast, McKeown’s approach requires a relatively longer graft for subsequent anastomosis, which challenges the preservation of the vessel arcade for the gastric conduit. In our case series, we preserved the RGEV as the feeding vessel to the remnant gastric conduit similar to prior studies (4,5). The operation time was longer than reported 195–275 minutes (5). We deemed that the lengthy operation time resulted from additional cervical procedure. In addition, the incidence of anastomotic leakage seemed higher (50%) than that in previous studies (0–22%) (4,5). In our view, this inferior result could not deny the feasibility of our technique in clinical practice owing to the small sample size. Compared to preserving the left gastric artery as feeding vessel (3), our technique was able to ensure a longer graft available. Moreover, our case report expanded the applicability of our technique from malignant disease to oxidative injury to the esophagus. This fact implies that our technique is feasible for a spectrum of diseases involving both esophagus and stomach.

The strength of this case series is that we demonstrate the feasibility of gastric conduit interposition with Roux-en-Y anastomotic technique in the setting of McKeown approach for patients requiring concurrent esophagectomy and distal gastrectomy for the first time in the literature. We believe our technique simplifies the procedure compared with either jejunal graft requiring microvascular anastomosis (8) or colonic graft highlighted by complex procedure (1). Meanwhile, there are several limitations to be addressed. First, the sample size is small, which might undermine the robustness of the conclusion in this article. We will further validate our technique in select patients. Second, no comparison was made with other grafts; therefore, we could not reach the conclusion that our technique is superior to others. Yet, the aim of this case series is just to show the feasibility of remnant gastric conduit in McKeown approach for select patients instead of in lieu of traditional grafts. Lastly, the insufficient follow-up period was unable to confirm the oncological efficacy of our technique in the treatment of patients with malignant disease.

Conclusions

In summary, our technique offers an alternative approach for the treatment of patients with concomitant esophageal and gastric diseases. Although its oncological efficacy needs to be examined with long-term follow-up, the feasibility of cervical gastroesophageal anastomosis makes it an alternative to colonic or jejunal graft in the setting of McKeown approach among select patients. Its feasibility will be further validated in clinical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-32/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-32/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-32/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this manuscript, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Honda M, Daiko H, Kinoshita T, et al. Minimally invasive resection of synchronous thoracic esophageal and gastric carcinomas followed by reconstruction: a case report. Surg Case Rep 2015;1:12. [Crossref] [PubMed]
2. Jiang R, Wang Y, Xu J, et al. Reconstruction using the colon or jejunum in patients with synchronous advanced esophageal and gastric cancers: a retrospective study from a single institutional database. BMC Surg 2023;23:175. [Crossref] [PubMed]
3. Xie S, Huang J, Kang G, et al. Surgical treatment of synchronous gastric and esophageal carcinoma: case report and review of literature. Thorac Cardiovasc Surg Rep 2013;2:35-7. [Crossref] [PubMed]
4. Zhao Y. Medicine (Baltimore) 2019;98:e14725. [Crossref] [PubMed]
5. Ding X, Li B, Shen H, et al. Evaluation of a new surgical procedure for simultaneous resection of synchronous thoracic middle-lower segment esophageal and distal gastric cancers. J Thorac Dis 2024;16:2236-43. [Crossref] [PubMed]
6. van Workum F, Slaman AE, van Berge Henegouwen MI, et al. Propensity Score-Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy. Ann Surg 2020;271:128-33. [Crossref] [PubMed]
7. Okamura A, Watanabe M, Okui J, et al. Esophagectomy for esophageal cancer in patients with a history of total pharyngolaryngectomy: a Japanese nationwide retrospective cohort study. Esophagus 2024;21:438-46. [Crossref] [PubMed]
8. Poh M, Selber JC, Skoracki R, et al. Technical challenges of total esophageal reconstruction using a supercharged jejunal flap. Ann Surg 2011;253:1122-9. [Crossref] [PubMed]