P1.247. Efficacy of a Cranial-First Approach During Laparoscopic Abdominal Procedures in McKeown Esophagectomy With Gastric Conduit Reconstruction

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique The proportion of minimally invasive surgery for esophageal cancer has been increasing, and laparoscopic abdominal procedures are now widely performed in subtotal esophagectomy. However, compared with open laparotomy, securing an adequate surgical field can be challenging, occasionally resulting in injury to the right gastroepiploic vessels or splenic injury. In our department, during laparoscopic abdominal procedures, we employ a cranial-first approach in which the gastrosplenic ligament is divided from the cranial side following dissection around the esophageal hiatus. We report the short-term outcomes of this technique. Between May 2024 and December 2025, 27 patients who underwent McKeown esophagectomy with our novel procedures were retrospectively analyzed for operative and short-term outcomes. The cranial-first approach was performed as follows: The median age was 70 years. Among 22 patients who received preoperative therapy, two underwent salvage surgery after chemoradiotherapy. Tumor location was distributed as follows: upper thoracic (Ut) 8, middle thoracic (Mt) 10, lower thoracic (Lt) 6, and esophagogastric junction (EGJ) 3. The median total operative time, including the thoracic phase, was 394 minutes (range, 325–497 minutes), and the median blood loss was 170 mL (range, 24–620 mL). The median operative time for the laparoscopic abdominal phase was 83 minutes (range, 59–120 minutes). Four patients developed anastomotic stricture classified as Clavien–Dindo grade ≥III, which was successfully managed with endoscopic balloon dilation. No anastomotic leakage was observed. The median postoperative hospital stay was 22 days (range, 14–62 days). The cranial-first laparoscopic approach for the abdominal phase of McKeown esophagectomy is feasible and can be performed safely, with a low incidence of anastomosis-related complications.