Multicenter retrospective study to evaluate the efficacy and safety of the double‐flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD‐FLAP Study)

Abstract

AimAs a result of the difficulty in effective prevention of gastroesophageal reflux, no standard reconstruction procedure after proximal gastrectomy (PG) has yet been established. The double‐flap technique (DFT), or Kamikawa procedure, is an antireflux reconstruction procedure in esophagogastrostomy. The efficacy of DFT has recently been reported in several studies. However, these were all single‐center studies with a limited number of cases.MethodsWe conducted a multicenter retrospective study in which patients who underwent DFT, irrespective of disease type and reconstruction approach, at each participating institution between 1996 and 2015 were registered. Primary endpoint was incidence of reflux esophagitis at 1‐year after surgery, and secondary endpoint was incidence of anastomosis‐related complications.ResultsOf 546 patients who were eligible for this study, 464 patients who had endoscopic examination at 1‐year follow up were evaluated for reflux esophagitis. Incidence of reflux esophagitis of all grades was 10.6% and that of grade B or higher was 6.0%. Male gender and anastomosis located in the mediastinum/intra‐thorax were independent risk factors for grade B or higher reflux esophagitis (odds ratio [OR]: 4.21, 95% confidence interval [CI]: 1.44‐10.9, P = 0.0109). Total incidence of anastomosis‐related complications was 7.2%, including leakage in 1.5%, strictures in 5.5% and bleeding in 0.6% of cases. Laparoscopic reconstruction was the only independent risk factor for anastomosis‐related complications (OR: 3.93, 95% CI: 1.93‐7.80, P = 0.0003).ConclusionDouble‐flap technique might be a feasible option after PG for effective prevention of reflux, although anastomotic stricture is a complication that must be well‐prepared for.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis

“…Their studies were 3 papers from china, Zhao et al [ 39 ], Zhang et al [ 24 ], and Hong et al [ 25 ], 23 papers from Japan, senmaru et al [ 26 ], kameyama et al [ 21 ], isobe et al [ 27 ], kazuhiro et al [ 28 ], adachi et al [ 29 ], kondoh et al [ 30 ], yasuda et al [ 32 ], ahn et al [ 45 ], nomura et al [ 33 ], sugiyama et al [ 46 ], tokunaga et al [ 35 ], ohashi et al [ 47 ], tanaka et al [ 38 ], aburatani et al . [ 40 ], nakamura et al [ 41 ], katai et al [ 16 ], masuzawa et al [ 42 ] and takayama et al [ 43 ], kano et al [ 44 ], koruda et al [ 22 ], omori et al [ 31 ], and saeki et al [ 37 ], 2 papers from Korea, Kim et al [ 23 ] and yang et al [ 34 ], and 1 paper from Scotland, wright et al [ 36 ]. Studies reported postoperative outcomes such as reflux esophagitis, anastomotic leakage, anastomotic stricture, and residual food shown in Table 2 .…”

“…Additionally, it was found that the preventive reflux methods within several techniques increased the incidence of residual food, reflux esophagitis, anastomotic stricture, and anastomotic leakage in all the reconstruction methods, but DFT recorded in the studies observed low incidence of complications 8.9%, 5.5%, 1.4% and 3.9% respectively. Individual studies also recorded a low incidence of complications [ 22 , 31 , 37 , 40 , 44 ]. DFT conducted after proximal gastrectomy seemed to be proven effective to lower the outcome as compared to the procedures of DTR, JPI, JI, and EG.…”

“…Four studies [22,31,37,44] reported double flap reconstruction with a total of 560 patients involved. Postoperative results including reflux esophagitis, anastomotic stricture, anastomotic leakage, and residual food were observed with an incidence of 8.9%, 5.5%, 1.4%, and 3.9% respectively.…”

“…DFT consists of a unique multistep process involving the creation of an H-shaped seromuscular double-flap, fixing the esophagus, and the gastric remnant, as well as anastomosis and closure of the double-flap, all of which are basically carried out by hand-sewn techniques. During this procedure, the distal esophagus and anastomosis are embedded in the submucosal layer of the gastric remnant and covered by the seromuscular double-flap, which is meant to function as a one-way valve to stop reflux [22].…”

Short-term and long-term comparisons of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy by the double-flap technique and laparoscopy-assisted total gastrectomy for proximal gastric cancer

“…DFT reconstruction, also known as the Kamikawa procedure, is an anti-reflux EG after PG, first reported by Kamikawa et al in 1998, in which the distal esophagus and the anastomosis are embedded into the submucosal space of the gastric remnant and covered by the seromuscular double-flap [ 6 , 7 ]. While DFT reconstruction has been reported to show acceptable short-term outcomes in preventing reflux esophagitis after surgery in a multicenter, retrospective study [ 8 ], there is little evidence of the long-term outcomes, including patients’ QOL.…”