Short Middle Overlap Anastomosis Reinforced with Toupet-like Fundoplication (SMART): A Novel Anti-Reflux Technique for Lower Mediastinal Esophagogastrostomy after Esophagogastric Junction Cancer Surgery.

Background: Lower mediastinal esophagogastrostomy after proximal gastrectomy with lower esophagectomy for esophagogastric junction (EGJ) cancer remains technically demanding due to the high risk of anastomotic leakage and reflux. We developed a novel reconstruction technique, the short middle overlap anastomosis reinforced with Toupet-like fundoplication (SMART) method, to address these challenges.

Methods: From March 2017 to April 2025, 40 patients underwent radical surgery for EGJ cancer at our institution. Among them, 10 patients with ≤3cm esophageal invasion received laparoscopic/robotic SMART esophagogastrostomy. The procedure consisted of an 8-cm esophageal overlap with the anterior gastric wall, a 2.5-cm linear stapled anastomosis at the midpoint, closure by Albert-Lembert suturing, and bilateral fixation of the esophagus to the stomach in a Toupet-like fashion. Short-term surgical outcomes were retrospectively analyzed.

Results: The median operative time and hospital stay were 452minutes and 9 days, respectively. No patients experienced anastomotic leakage or stenosis. Mild reflux symptoms and endoscopic reflux esophagitis were observed in 2 patients (Grade A and B). The mean body weight loss at 6 months postoperatively was 5.5% compared to baseline.

Conclusion: The SMART method appears to be a safe, feasible, and anti-reflux reconstruction technique for lower mediastinal esophagogastrostomy following EGJ cancer surgery. Although preliminary, our findings suggest it may offer a promising option, warranting further investigation.