# Risk Factors for Anastomotic Stricture and Obstructive Symptoms Following Double‐Flap Technique Reconstruction After Proximal Gastrectomy

## TL;DR

This study identifies risk factors for anastomotic stricture and obstructive symptoms after a surgical technique used in stomach surgery, offering ways to improve patient outcomes.

## Contribution

The study identifies mucosal detachment and continuous suturing as novel risk factors for complications after double-flap technique reconstruction.

## Key findings

- Mucosal detachment of the esophagus is a significant risk factor for anastomotic stricture after DFT reconstruction.
- Continuous suturing at the E-S fixation site increases intraluminal pressure and obstructive symptoms.
- Thermal damage during surgery may contribute to mucosal detachment and subsequent complications.

## Abstract

The double‐flap technique (DFT) is a widely used esophagogastrostomy method after proximal gastrectomy (PG) due to its strong anti‐reflux mechanism. However, anastomotic stricture remains a major concern, leading to obstructive symptoms and impaired postoperative quality of life (QOL). This study aimed to identify risk factors for anastomotic stricture and obstructive symptoms after PG with DFT reconstruction.

This single‐center, retrospective study analyzed 77 patients who underwent DFT reconstruction between 2014 and 2022. The impact of technical factors, including suturing methods and mucosal detachment, was evaluated. In addition, intraluminal pressure analysis was performed using ex vivo pig stomach models to assess sites contributing to obstructive symptoms.

Anastomotic stricture requiring balloon dilatation occurred in 10 patients (13%), with mucosal detachment of the esophagus identified as an independent risk factor (odds ratio [OR]: 48, 95% confidence interval [CI]: 4.47–515, p = 0.001). Thermal damage during esophageal transection was a potential risk factor for mucosal detachment (OR: 6.63, 95% CI: 1.00–44.1, p = 0.051). Moderate or severe obstructive symptoms 1 month after surgery were reported by 59% of patients, with continuous suturing for esophago‐stomach fixation (E‐S fixation) increasing the risk (OR: 4.50, 95% CI: 0.98–20.7, p = 0.054). Intraluminal pressure analysis confirmed that continuous suturing at the E‐S fixation site significantly increased pressure compared with interrupted suturing (p = 0.028).

Preventing mucosal detachment by minimizing thermal damage can reduce anastomotic stricture. Further, interrupted suturing at the E‐S fixation site may reduce obstructive symptoms. These findings provide insights into optimizing DFT reconstruction to improve postoperative outcomes and patient QOL.

This retrospective study investigated risk factors for anastomotic stricture and obstructive symptoms following double‐flap technique (DFT) reconstruction after proximal gastrectomy. Mucosal detachment, potentially caused by thermal damage, was identified as a significant risk factor for anastomotic stricture, while continuous suturing at the esophago‐stomach fixation site increased intraluminal pressure and obstructive symptoms. Minimizing thermal injury and using interrupted sutures may optimize DFT outcomes and improve postoperative quality of life.