Duodenogastric reflux after esophagectomy and gastric pull-up: The effect of the route of reconstruction

Duodenogastric reflux (DGR) is a common sequel of subtotal esophagectomy and gastric pull-up, and it may contribute to mucosal changes of both the gastric conduit and the esophageal remnant. This study investigated the effect of the route of reconstruction on the DGR. 24-hour ambulatory bilirubin monitoring was performed on patients who underwent transhiatal subtotal esophagectomy and a gastric tube interposition either in the posterior mediastinum (PM group, n = 11), or in the retrosternal space (RS group, n = 8): A Control group of 8 healthy volunteers was also studied. The median percentage of reflux time, the median number of reflux episodes, and the median number of reflux episodes longer than 5 minutes, in PM versus RS groups, were 29.1% versus 0.15% (p < 0.001), 185 versus 8 (p = 0.002) and 10 versus 0 (p = 0.001), respectively. The values of the above variables in PM versus control groups were 29.1% versus 3.95% (p = 0.007), 185 versus 21 (p = 0.02), and 10 versus 2 (p = 0.009), respectively, whereas in RS versus control groups they were 0.15% versus 3.95% (p = 0.01), 8 versus 21 (p = 0.04), and 0 versus 2 (p = 0.05), respectively. Posterior mediastinal gastric interposition is associated with high reflux of duodenal contents, whereas retrosternal interposition minimizes the reflux at levels even lower than those of the healthy individuals. The latter type of reconstruction may be a good alternative from that perspective, especially in patients with long life expectancy.