A Retrospective Review of a Single-Center Experience with Posterolateral Fundoplication During Esophagogastrostomy After Proximal Gastrectomy

For patients with proximal gastric cancer (PGC), proximal gastrectomy (PG) has been proposed as a surgical option with the expectation of ameliorating postgastrectomy syndrome. Although esophagogastrostomy with a large remnant stomach is a simple reconstruction method that allows gastric functions and capacity to accommodate food to be preserved, patients undergoing this procedure often develop severe reflux esophagitis. 2 At present, esophagogastrostomy with an additional antireflux procedure is considered as the most promising reconstruction technique. Herein, we report our exper i ence wi th the addi t ion of the pos te ro la te ra l fundoplicat ion (PLF) technique to the standard esophagogastric anastomosis.


Introduction
For patients with proximal gastric cancer (PGC), proximal gastrectomy (PG) has been proposed as a surgical option with the expectation of ameliorating postgastrectomy syndrome. Although esophagogastrostomy with a large remnant stomach is a simple reconstruction method that allows gastric functions and capacity to accommodate food to be preserved, patients undergoing this procedure often develop severe reflux esophagitis. 1,2 At present, esophagogastrostomy with an additional antireflux procedure is considered as the most promising reconstruction technique. [3][4][5] Herein, we report our exper i e n c e w i t h t h e a d di t i o n o f t he p o s t e r o l a t e r a l fundoplication (PLF) technique to the standard esophagogastric anastomosis.

Methods
The schema of PLF is shown in Fig. 1a. After PG with D1+ regional lymphadenectomy, esophagogastrostomy using a mechanical circular stapler was performed at the anterior wall of the remnant stomach, the center of which was up to a length of 40 mm from the cut end of the stomach. Then, the cut end of the stomach was fixed to both the top posterior end of the freed esophageal wall and the diaphragm. Finally, the posterior half-circumference of the esophagus was wrapped with the anterior gastric wall by placing stay sutures.
After obtaining approval from the ethics board for this study, the data of 28 patients who underwent PLF between July 2016 and December 2019 was reviewed.

Results
The clinicopathological features and postoperative findings are summarized in Table 1. The surgery was performed by the laparoscopic approach in 23 patients. Seven patients developed benign membranous stricture several months after surgery, all of the seven patients were successfully treated by endoscopic mechanical dilatation. The PLF was maintained during over years ( Fig. 1b-d). None of the patients developed either endoscopic or clinical evidence of reflux esophagitis.

Discussion
The PLF procedure is simple. The proposed physiology underlying the antireflux effect of PLF is shown in Fig. 1e. The 180°wrapping of the esophagus with the anterior gastric wall forms the internal valve. Furthermore, the stretch of the gastric wall pulls the side wall of the esophagus on either side in the lateral direction. While the remnant stomach becomes filled with contents, the lumen of the esophagus closes, and does not open until the remnant stomach becomes empty.
Though the safety of PLF was acceptable, development of anastomotic stenosis was the lone worrisome event. Stenosis developing after mechanical esophagogastrostomy has been reported to be not life-threatening and as being treatable by mechanical dilatation. 6 Patients in whom the entire abdominal esophagus and more than half of the stomach can be preserved are a suitable indication of PLF. In regard to the oncological safety, the noninferiority of PG to total gastrectomy remains to be established. Hence, in Japan, the indication of PG for patients with PGC is generally limited to patients with clinical stage T1N0 disease.
There were limitations of the present study. First, this was a retrospective study with a small sample size. Second, supportive evidence to validate the rationale for PLF is still lacking. Third, a comparison of different antireflux procedures is needed to establish the optimal antireflux procedure.

Conclusion
Esophagogastrostomy with PLF is a promising reconstruction procedure after PG.
Author contribution Substantial contribution to the conception of this work and drafting of this manuscript: Masaki Aizawa Acquisition and analysis of data: Atsushi Matsuki and Takeo Bamba Critical revision of the work for important intellectual content: Hiroshi Yabusaki, Koji Nakada, and Satoru Nakagawa All authors agree to be accountable for all aspects of the work and to ensure that questions related to the accuracy and integrity of any part of the work have been appropriately investigated and resolved.

Declarations
Ethics approval and consent to participate All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. The study was conducted with the approval of our Institutional Review Board.
Sex-inclusive reporting The subjects' sex was not considered as a biologic variable in this work.

Conflict of interest The authors have no conflicts of interests to declare.
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