A novel valvuloplastic esophagogastrostomy for laparoscopic proximal gastrectomy: Parachute-tunnel-style technique and animal experiments of relationship between anastomotic stenosis and gastric remnant seromuscular flap blood supply.

[BACKGROUND] Among several esophagogastric anastomosis techniques with additional mechanical antireflux functions after laparoscopic proximal gastrectomy (LPG), the double-flap technique (DFT) has received increased attention recently. However, some issues related to the central incision in the gastric seromuscular flap of the DFT still warrant further exploration. The incidence of anastomotic stricture in DFT remains a problem that cannot be ignored. To date, there have been no reports that have focused on the relationship between the blood supply of the flap and anastomotic stenosis. Thus, a novel valvuloplastic esophagogastrostomy for LPG, termed parachute-tunnel-style technique (PTST), was developed. In addition, an animal experiment was conducted to explore whether the flap blood supply plays a key role in the stenosis of the anastomosis or not.

[METHODS] After reviewing our institution's prospective gastric cancer database, 23 consecutive patients who underwent LPG with valvuloplastic esophagogastrostomy using PTST between December 2022 and September 2024 were included in this study. Short- and middle-term surgical outcomes were analyzed to investigate the safety, feasibility, and antireflux function of PTST. For the animal experiment, the DFT and PTST Bama miniature pig animal models (6 cases in each group) were established using open surgery and an infrared laser speckle flowmeter to quantify the flap blood supply and to explore the potential relationship between the flap blood supply and the anatomical geometry of the reconstructed structure.

[RESULTS] The mean total operative time was 341.0 ± 62.3 min. The mean anastomotic time was 47.3 ± 12.5 min. Postoperatively, 1 patient experienced anastomotic stenosis. Another patient developed esophageal perforation at the esophagogastric fixation suture site. No reflux esophagitis was observed in all patients, and optimal quality of life and nutrition status were also achieved in most patients during at least 6 months of follow-up. In the animal experiment, the mean blood supply of the flap in the DFT group was much lower than that in the PTST group (350.51 ± 66.82 vs 483.45 ± 99.98 PU, respectively; P <.05). In both groups, there was 1 case each that developed anastomotic stenosis. Interestingly, in the 2 cases in which anastomotic stenosis occurred, the length of the reconstructed gastroesophageal valve was significantly shorter than that of the other cases without anastomotic stenosis (1.75 cm [IQR, 1.60-1.90] vs 2.75 cm (IQR, 2.20-3.20], respectively; P <.05).

[CONCLUSION] The PTST can significantly shorten the anastomosing time, reduce the operational difficulty, and result in an excellent antireflux function, indicating that this technique is safe and feasible for valvuloplastic esophagogastrostomy after LPG. The results of the animal experiments suggest that the anastomotic stenosis might be more related to the local mechanical tension of the anastomosis than the compromised blood supply of the flap.