After esophagectomy, patients commonly experience gastrointestinal symptoms, such as delayed gastric emptying, early satiety, reflux, and dumping syndrome. These symptoms, if prolonged, can lead to weight loss, malnutrition, and recurrent aspiration pneumonia, significantly impacting a patient's ability to perform ADL and QOL [1]. While many patients respond well to medications or endoscopic procedures, some may require surgery. GCO or severe delayed gastric conduit emptying (DGCE) are indications for surgical intervention [4]. While most cases of GCO are caused by mechanical obstruction and most cases of severe DGCE are caused by functional obstruction, there have been reports of revision surgery for both types. There can be overlap between reported cases of severe DGCE and GCO, leading to a confusion regarding how these terms are used. The need for revision surgery has been reported in 1.1–3.7% of cases [2, 3]. Kent et al. [3] reported that mechanical obstructions, such as diaphragmatic hernia, twisted conduit, stenosis of the pyloric ring or the esophageal hiatus, and functional obstructions, such as excess conduit left above the diaphragm during the initial esophagectomy or a sigmoid-shaped conduit without evidence of outflow obstruction, can necessitate revision surgery. Twisted conduit can be determined using CT confirming the running of the staple line and by the endoscopic whole finding of the gastric folds. Functional obstruction is caused by a combination of factors including dysfunction of the pylorus and gastric peristalsis owing to vagotomy, negative pressure in the thoracic cavity, disruption of the anti-reflux mechanism, size of the conduit, and the route of reconstruction [6].

Substernal (ST) and posterior mediastinal (PM) routes are commonly used for reconstruction after esophagectomy with cervical anastomosis. While revision surgery has been reported in cases both ST route [7,8,9] and PM route [4, 10] for reconstruction. Our case involved a patient who underwent revision surgery following a PM route reconstruction. It is likely that the gastric conduit was easily pulled into the mediastinum due to the combination of insufficient adhesion between the posterior half of the conduit wall and the diaphragmatic crura, inadequate fixation of the conduit during the initial surgery, and the negative pressure within the thoracic cavity. The formation of the band is presumed to be influenced by postoperative changes resulting from surgical maneuvers such lymph node dissection of inferior mediastinum. This complication can be attributed to a combination of factors: inadequate fixation of the gastric conduit during the initial surgery, a lack of adhesion on the posterior side of the conduit around esophageal hiatus, and adhesion of the thoracic side caused after surgical maneuvers. These findings highlight the increased risk of conduit displacement in MIS when inadequate fixation is performed, emphasizing the importance of developing fixation methods that minimize the risk of displacement. In our institution, during the initial surgery, only two or three anchor stitches were placed in the anterior wall of the gastric conduit to prevent entry into the mediastinum (Fig. 6a). This prompted us to add anchor stitches between the crus and the gastric conduit from the right lateral side to the posterior side (Fig. 6b). Since implementing this technique, our institution has not encountered any cases of gastric conduit displacement into the mediastinum. We believe this approach is a feasible and effective method for preventing this complication. To our best knowledge, this is the first detailed report of laparoscopic repair for obstruction caused by a gastric conduit with subsequent band formation proximal to the pylorus, leading to torsion.

Fixation of the gastric conduit during reconstruction of the posterior mediastinal routes in our hospital. a Fixation of the anterior side of the gastric conduit alone leaves a space on the dorsal side (yellow dotted space). b In addition to the anterior wall of the gastric conduit (yellow arrow), an anchor suture is added on the right side of the conduit, closer to the dorsal side (red arrow)

Ganeshan et al. [11] reported that patients with a higher BMI (> 25 kg/m2) may have a lower propensity to suffer from post-esophagectomy diaphragmatic hernia. They theorized that the obscuring of the esophageal hiatus may be due to an increase in intra-abdominal fat mass. Our patient experienced a weight loss of 6 kg after adjuvant chemotherapy, suggesting a reduction in intra-abdominal fat mass. This may have led to a decrease in the volume of omentum within the esophageal hiatus, making it easier for the gastric conduit to deviate into the thoracic cavity. Therefore, postoperative weight loss may also be a potential contributing factor to the ease with which the gastric conduit deviated into the thoracic cavity in our case.

Regarding revision surgery, there are reports of open laparotomy and thoracotomy [4, 8, 9], as well as minimally invasive approaches (laparoscopy, laparoscopy and thoracoscopy) [4, 12, 13]. There are a few different techniques for revision surgery, including pulling the gastric conduit back into the abdominal cavity and re-fixing it to the crus of the diaphragm [8, 9, 12], or creating a bypass [7, 10]. Given that our patient underwent a post-robotic assisted minimally invasive esophagectomy (MIE) and only minimal adhesion in the abdominal cavity was anticipated, laparoscopic surgery was chosen and successfully completed. With the increasing adoption of MIE, laparoscopic revision surgery is likely to become a more common approach.

During intraoperative manipulation, meticulous care should be taken to avoid damage to the gastric conduit blood flow, particularly the right gastroepiploic artery and vein, and the right gastric artery. In this case, the lack of significant intra-abdominal fat facilitated easy identification of these structures. However, in cases where direct visualization is not possible, the ICG fluorescence method can be a valuable tool for confirming vascular integrity [9]. It is crucial to be aware that in certain situations, such as those with abundant intra-abdominal fat, it may be challenging to directly visualize these vessels. Therefore, careful techniques and a focus on minimizing the risk of compromising gastric conduit blood flow are essential during revision surgery.

In this case, we repeatedly used an intraoperative endoscope to check the lumen of the gastric conduit. Preoperatively, there was a significant flexure in the conduit. The surgery was completed only after we confirmed that the flexure had finally been released. Initially, we believed that we had successfully released the adhesions around the diaphragm and straightened the conduit. However, the intraoperative endoscope revealed that the flexure had not been fully resolved. This prompted a further search towards the pyloric end of the conduit, where we discovered band formation as the underlying cause of the persistent flexure.