Background: Locally advanced gastroesophageal junction (GEJ) tumors are surgically challenging, requiring balance between R0 resection and preserving quality of life.<CitationRef CitationID="CR1">1</CitationRef> Total gastrectomy has been the standard approach, but function-preserving strategies are increasingly used to mitigate the nutritional and hormonal consequences associated with complete stomach removal.<CitationRef CitationID="CR2">2</CitationRef>Proximal gastrectomy (PG) with esophagogastric anastomosis preserves gastric volume but is frequently complicated by severe reflux and anastomotic strictures.<CitationRef CitationID="CR3">3</CitationRef> Double-tract reconstruction (DTR) has emerged as an alternative. Recent meta-analyses have demonstrated that DTR reduces reflux and stricture rates compared with esophagogastric anastomosis while maintaining 5-year overall survival comparable with total gastrectomy.<CitationRef CitationID="CR4">4</CitationRef>,<CitationRef CitationID="CR5">5</CitationRef> Methods: This study demonstrated robotic PG-DTR and en bloc distal pancreatectomy with splenectomy (DPS) for a 70-year-old man with Siewert type II GEJ adenocarcinoma. Results: After a favorable response to neoadjuvant FOLFOX chemotherapy, the patient underwent resection. The case was completed in less than 6 h. Pathology showed a 6.3-cm, moderately differentiated T4bN2 adenocarcinoma. Despite advanced-stage disease and indications of peritoneal spread, the patient had prompt recovery (Fig. <InternalRef RefID="Fig1">1</InternalRef>). Key considerations included careful patient selection after preoperative chemotherapy and achievement of R0 resection with meticulous mediastinal and oncologic lymph node dissection. For optimal functional outcomes and prevention of internal hernias, the authors perform hand-sewn esophagojejunostomy, appropriate spacing between the esophagojejunostomy and gastrojejunostomy, upright fixation of the remnant stomach, and closure of the hiatal, mesenteric, and Petersen defects. Conclusion: This case demonstrates that PG-DTR and en bloc DPS are feasible and may provide functional benefits for select patients who have locally advanced GEJ tumors with direct pancreatic invasion. The robotic approach may enhance postoperative recovery, supporting early resumption of systemic therapy.

Robotic Multivisceral Resection for Gastroesophageal Junction Tumor: Proximal Gastrectomy with Double-Tract Reconstruction and Distal Pancreatectomy

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2026年6月14日

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Anneliese N. Hierl,
Taisuke Imamura,
Brian D. Badgwell,
Paul F. Mansfield,
Naruhiko Ikoma

摘要

Background:

Locally advanced gastroesophageal junction (GEJ) tumors are surgically challenging, requiring balance between R0 resection and preserving quality of life.¹ Total gastrectomy has been the standard approach, but function-preserving strategies are increasingly used to mitigate the nutritional and hormonal consequences associated with complete stomach removal.²Proximal gastrectomy (PG) with esophagogastric anastomosis preserves gastric volume but is frequently complicated by severe reflux and anastomotic strictures.³ Double-tract reconstruction (DTR) has emerged as an alternative. Recent meta-analyses have demonstrated that DTR reduces reflux and stricture rates compared with esophagogastric anastomosis while maintaining 5-year overall survival comparable with total gastrectomy.^4,5

Methods:

This study demonstrated robotic PG-DTR and en bloc distal pancreatectomy with splenectomy (DPS) for a 70-year-old man with Siewert type II GEJ adenocarcinoma.

Results:

After a favorable response to neoadjuvant FOLFOX chemotherapy, the patient underwent resection. The case was completed in less than 6 h. Pathology showed a 6.3-cm, moderately differentiated T4bN2 adenocarcinoma. Despite advanced-stage disease and indications of peritoneal spread, the patient had prompt recovery (Fig. 1). Key considerations included careful patient selection after preoperative chemotherapy and achievement of R0 resection with meticulous mediastinal and oncologic lymph node dissection. For optimal functional outcomes and prevention of internal hernias, the authors perform hand-sewn esophagojejunostomy, appropriate spacing between the esophagojejunostomy and gastrojejunostomy, upright fixation of the remnant stomach, and closure of the hiatal, mesenteric, and Petersen defects.

Conclusion:

This case demonstrates that PG-DTR and en bloc DPS are feasible and may provide functional benefits for select patients who have locally advanced GEJ tumors with direct pancreatic invasion. The robotic approach may enhance postoperative recovery, supporting early resumption of systemic therapy.