Feasibility of surgical resection for gastric cancer in the gastric conduit following esophagectomy for esophageal squamous cell carcinoma

Introduction

Gastric conduit cancer (GCC) is a rare but increasingly recognized long-term complication following esophagectomy for esophageal cancer. The stomach remains the most frequently utilized conduit for this esophageal reconstruction due to its robust and consistent blood supply, close proximity, reliable reach to cervical or thoracic anastomosis with minimal tension, and easy to handling during surgery. While nonsurgical treatments such as definitive chemoradiotherapy and immunotherapy have expanded the therapeutic options for esophageal squamous cell carcinoma (SCC), esophagectomy continues to be widely performed, particularly in patients with resectable disease and good performance status (1). Improvements in surgical technique, perioperative care, and patient selection have contributed significantly to enhanced survival rates in recent years.

With longer survival after esophagectomy, the clinical significance of GCC is increasing (2). The reported incidence of GCC is approximately 2.4% at 5 years and 5.7% at 10 years postoperatively (3). The interval between the esophagectomy and the development of GCC ranged from one to nine years (4,5). Given that many of these patients have undergone neoadjuvant chemoradiation before esophagectomy, further radiation may not be feasible. Surgery for the altered anatomy and physiology of the gastric conduit is associated with significant morbidity and mortality (6). This study aims to evaluate the safety and feasibility of surgical resection for GCC following esophagectomy, and to characterize the postoperative outcomes given the anatomical alterations and technical challenges inherent in re-operative upper gastrointestinal surgery. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-441/rc).

Methods

This study was approved by the ethics committee of Shanghai Chest Hospital (No. IS24164). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments (7). Individual consent for this retrospective analysis was waived. Patient anonymity was preserved throughout the research process, ensuring confidentiality in all aspects of data collection and analysis.

Patients with GCC after esophagectomy from June 2019 to June 2024 were identified from the medical record system. Although this was a retrospective review, all clinical, operative, and follow-up data were prospectively collected in a standardized institutional database from the time of each patient’s initial presentation. Relevant data were then retrospectively retrieved and analyzed for this study.

The primary objective of this study was to evaluate the safety and feasibility of surgical resection for GCC after esophagectomy. Safety was defined based on three main criteria: (I) the absence of 30- and 90-day postoperative mortality; (II) the incidence of major complications Clavien-Dindo (C-D) classification ≥ grade IIIa; and (III) the need for unplanned reoperations during the index hospitalization. Feasibility was assessed based on: (I) successful completion of intended surgical resections without abandonment or unplanned staging; (II) the reconstructive techniques successfully employed; and (III) operative efficiency, measured by intraoperative blood loss and operative time.

In addition to the primary outcome, several secondary outcomes were assessed to provide a more comprehensive understanding of the therapeutic impact of surgery. These included measures of oncologic adequacy such as the rate of R0 resection, incidence of anastomotic leakage, length of hospital stay, duration of intensive care unit (ICU) admission, and 30-day readmission rates. Overall survival (OS) at 1 and 2 years was also documented to assess longer-term outcomes.

All patients included in the study had a history of esophageal SCC with digestive reconstruction by stomach. Most patients were referred from external institutions specifically for the possibilities of surgical management of GCC, and their initial esophagectomies were performed elsewhere. As this study includes referred cases from multiple institutions, a true incidence rate of GCC could not be calculated from within a defined esophagectomy cohort. All the patients included in the study underwent surgical intervention to address the GCC. Patients with incomplete medical records were excluded from the study (Figure 1).

Figure 1 Study flowchart. *, Exception case 12, partial resection of the gastric conduit was performed, and reconstruction utilized the remaining stomach.

In order to describe the location of GCC, the gastric conduit was divided into three regions: the anastomosis site (upper third), body (middle third), antrum and pylorus (distal third). Cancer staging for gastric cancer was based on the eighth edition of the TNM classification (8). 18F-fuorodeoxyglucose-positron emission tomography (PET) was performed in selected patients. Endoscopic ultrasound (EUS) was not performed as a routine part of staging. EUS is frequently difficult or infeasible in the gastric conduit due to altered anatomy, limited scope maneuverability, postoperative adhesions, and the difficulty of accessing lesions near the upper thoracic inlet or anastomotic site.

Surgical planning and conduit selection were guided by tumor location, prior surgical history, and intraoperative findings. In general, tumors in the proximal or middle third of the gastric conduit typically require total gastrectomy, particularly when the tumor is near the anastomosis or extended across multiple segments. In these cases, colonic interposition was favored for reconstruction due to its adequate length and vascular reliability for reaching the cervical esophagus via the retrosternal route.

Tumors located in the distal third were evaluated for partial gastrectomy when oncologically feasible. However, total gastrectomy was still performed in most of these cases due to compromised gastric conduit perfusion, dense adhesions, or insufficient margin clearance. Reconstruction was performed using jejunal Roux-en-Y or colon, depending on the required reach and vascular anatomy. Final surgical decisions were often refined intraoperatively based on anatomical findings and technical feasibility, prioritizing oncologic clearance and minimizing complication risk.

Perigastric lymphadenectomy was routinely performed in patients undergoing total gastrectomy, in line with oncologic principles. However, in cases of partial gastrectomy, the extent of dissection was limited to preserve the right gastroepiploic arcade, which often served as the primary vascular supply to the remaining conduit. In addition, mediastinal lymph node dissection was routinely performed in patients with middle or proximal third tumors, due to anatomical proximity. Cervical nodal stations were dissected selectively when oncoperative PET-computed tomography (CT) imaging suggested nodal involvement.

This study adopted the C-D classification method to document the postoperative complications of the patients, specifically identifying the highest grade of complication for each patient (9). Every patient in this study had regular postoperative outpatient assessments according to our institutional protocol: every 3–4 months in the first two years, every six months between years three and five, annually thereafter. Follow-up assessments included upper gastrointestinal endoscopy and contrast-enhanced CT scan. This follow-up schedule applied specifically to patients following resection of GCC and was adapted as needed based on individual clinical status and external care factors. No patients were lost to follow-up. Follow-up data were obtained through a combination of scheduled clinic visits, routine surveillance imaging, and direct telephone contact with patients or their families when in-person visits were missed to verify survival and recurrence status.

Statistical analysis

All data were presented as means ± standard deviation (SD) or medians with interquartile range (IQR) and total ranges unless stated. Kaplan-Meier curves were used to delineate the survival rate. A P<0.05 was statistically significant. All statistical analyses were performed using the SPSS software package (version 29.0, IBM Corp.).

Results

Patient characteristics (Table 1)

Seventeen patients were included in the study, with a median age of 66 years. The cohort comprised 16 male patients and one female patient. Of these, 16 had undergone prior esophagectomy at an external institution for esophageal SCC. Due to the referral-based nature of this cohort, no additional information was available regarding the clinicopathological characteristics of the SCC, including perioperative treatment. Among the patients, 53% (n=9) were smokers, and 29% (n=5) had a history of alcohol consumption.

Of the 17 patients, eight (47%) had a McKeown esophagectomy, seven (41%) of them underwent Sweet esophagectomy and two (12%) of them underwent Ivor Lewis esophagectomy. All tumors were exclusively adenocarcinoma. As shown in Figure 2, the median interval between esophagectomy and diagnosis of GCC was 84 months (IQR 48–180 months). A total of six (35%) of them were in the proximal third of the gastric conduit, in close proximity to the anastomosis site. Additionally, six (35%) of them were detected in the middle third of the body of the stomach, while just five (30%) were found in the distal third of the stomach. Eleven patients (65%) had PET as part of the staging prior to surgery.

Figure 2 Interval from esophagectomy to diagnosis of gastric conduit cancer.

Primary outcomes

Safety

No 30- and 90-day mortality was observed. A total of 59% of patients encountered postoperative complications of varying degrees of severity; 41% of them were minor (C-D < grade III). Of the patients, 24% (n=4) experienced grade II complications, while 18% (n=3) experienced grade I complications. Three patients (18%) experienced major complications (grade IIIa), all of which were pulmonary in nature. Two of them required the reinsertion of their chest tubes due to pneumothorax, while one required image-guided pigtail drainage to address worsening right pleural effusion (Table 1). An anastomotic leakage occurred in one patient but was successfully managed conservatively. No complications beyond grade IIIa were observed.

Postoperative recurrent laryngeal nerve (RLN) palsy was observed in five patients (29%), all of whom exhibited unilateral paralysis with mild hoarseness.

Feasibility

All intended surgical resections were successfully completed without abandonment or conversion to unplanned staged procedures. All surgeries were performed via open technique. A total of 14 patients underwent total gastrectomy, while 3 had partial gastrectomy. Reconstructions were achieved using colon in 65% (n=11), jejunum in 29% (n=5), and the remaining stomach in 1 case (6%). The retrosternal route was employed in 71% (n=12) and the posterior mediastinum route in 24% (n=4) of them. One (6%) of them had their reconstruction performed intra-peritoneally with anastomosis performed in the abdominal cavity. The surgical strategies used for reconstruction are illustrated in Figure 3. The mean operative time was 384±129 minutes and the median intraoperative blood loss was 100 mL (IQR 100–150 mL).

Figure 3 Surgical approaches for gastric conduit cancer and reconstruction. (A) Segmental resection of gastric conduit with reanastomosis; (B) colonic interposition; (C) partial gastrectomy with Roux-en-Y reconstruction; (D) Roux-en-Y reconstruction with thoracic anastomosis.

Secondary outcomes

Oncologic adequacy and perioperative measures

R0 resection was achieved in 82% (n=14) of cases, microscopically positive (R1) in 18% (n=3), and no cases had macroscopic residual disease (R2). Two R1 cases are involved. Among the three patients with R1 resection, two were due to circumferential margin involvement in tumors located in the proximal third of the gastric conduit. The third patient, who underwent distal gastrectomy with intraperitoneal reconstruction, had a microscopically positive proximal resection margin as confirmed on final pathology.

Among the 17 patients, 6 had pathological nodal metastases. Thoracic nodal stations were most commonly involved, including stations 106recL (n=3), 106recR (n=1), 107 (n=2), 104 (n=1), 101 (n=1), and 109L (n=1). One patient had nodal involvement at abdominal station 3a. Postoperatively, six of these patients received adjuvant treatment (Table 1).

Postoperatively, the patient will be routinely transferred to the ICU. The median length of ICU stay was 2 days (IQR 1–4 days) and the median postoperative hospital stay was 11 days (IQR 9–15 days). No patient required ICU readmission or unplanned postoperative intervention. No 30-day hospital readmissions were reported in this cohort.

Survival outcomes

The median follow-up duration for survivors was 17 months (IQR 11–35 months). The 1- and 2-year survival rates were 76% [95% confidence interval (CI): 56.3–96.7%] and 59% (95% CI: 33.1–86.1%), respectively (Figure 4). Of the six total deaths, only one patient developed confirmed distant lung metastasis and died from cancer-related disease progression. No locoregional recurrences were documented. Three deaths were non-cancer-related causes: one from persistent poor oral intake, one from severe hypoalbuminemia and one from intestinal obstruction; all had no clinical or radiological evidence of cancer recurrence. Two deaths occurred outside the treating institution, and while death was confirmed through follow-up contact, the specific causes of death could not be verified.

Figure 4 Kaplan-Meier survival curve with number at risk.

Discussion

This study offers crucial insights into the surgical treatment of GCC, a rare yet challenging condition. Building on the systematic review by Gentile et al. in 2019 (10), this case series represents the second largest cohort to undergo surgical treatment for GCC. The largest published series by Toyoshima et al. focused on Roux-en-Y reconstruction after partial or total gastrectomy (11). Given the high morbidity and mortality associated with re-operation, this study provides a more in-depth evaluation of various surgical strategies in the management of GCC.

Gastric cancer is highly prevalent in East Asia, and using the stomach as a neo-esophagus poses a similar risk. While esophageal cancer is associated with a higher risk of developing secondary malignancies, including head and neck cancers, these are primarily due to shared etiological exposures such as tobacco, alcohol and dietary habits (12). In contrast, GCC is a distinct entity, driven more by post-surgical changes. An altered physiology of the gastric conduit, including long-term bile reflux, may contribute to intestinal metaplasia and increased risk of malignancy (13,14).

The study showed the median time span between esophagectomy and GCC diagnosis was 84 months [IQR 48–180 months], highlighting a delayed onset pattern. Although guidelines for post-esophagectomy surveillance remain variable, a nationwide survey by Nakanoko et al. [2022] found that most Japanese institutions performed annual endoscopy and CT for the first 5 years, with over 70% continuing surveillance to year 10 (12). Nevertheless, practices remained inconsistent, with only 25–30% of centers actively screening for metachronous head and neck cancers (12). These results reinforce the value of consistent, long-term surveillance beyond five years to facilitate early detection and increase eligibility for less invasive treatment approaches in selected patients.

For early-stage GCC, endoscopic resection is the preferred approach, offering excellent outcomes with minimal invasiveness. A nationwide study by Ota et al. (2022) showed that early detection enabled higher rates of successful endoscopic treatment, with a 5-year OS of 75.9% compared to 52.7% for surgery (15). Although endoscopy treatment is recommended, one needs to consider the difficulties encountered. These clinical decisions are supported by findings of Meng et al. (2023), whose meta-analysis reported that although ESD yields favorable outcomes in early-stage metachronous gastric cancer, its applicability is limited (16).

In our cohort, two patients with pathological stage IA disease were not candidates for endoscopic resection. One had a 4 cm T1a lesion in the distal third of the gastric conduit with ulceration and a broad base, raising the concern for incomplete resection. The second had a T1b lesion in the middle third of the conduit, with poor differentiation and endoscopic features suggestive of submucosal invasion. EUS was not feasible in either case due to the altered anatomy post-esophagectomy, which limited the accurate depth assessment.

Our study affirms both the safety and technical feasibility of surgery for GCC. All patients underwent intended resection without intraoperative abandonment or unplanned staging. Diverse reconstruction methods were successfully tailored to tumor location and prior anatomy. The observed 1- and 2-year survival rates of 76% and 59% compare favorably to historical benchmarks (Table 2), while our C-D complication profile appears particularly noteworthy. Only 18% of patients experienced major complications (grade IIIa or higher), contrasting sharply with 25–83% rates reported in comparable series. This included a single anastomotic leak managed conservatively and no life-threatening events (grade IV/V) or perioperative deaths, whereas prior studies like Yoon et al. [2011] documented 83% major morbidity dominated by respiratory failure and leak, and Urabe et al. [2021] reported 33 % complications (6,18).

The improved safety profile in our series stems from several technical factors. First, the adoption of intraserosal resection near the trachea and RLN to avoid injuries to critical structures enabled 82% R0 margins while limiting nerve palsy to 29% unilateral cases. At the tumor site, we ensured full-thickness en bloc resection to maintain oncologic adequacy. Second, retrosternal routing was employed in 71% of reconstructions, enabling safer planes of dissection away from hostile mediastinal adhesions. Third, conduit selection favored colonic interposition (65%) for proximal tumors and jejunal Roux-en-Y for distal lesions, resulted in only one anastomotic leak (5.9%), consistent with Toyoshima et al. [2023] findings of higher leak rates (15–25%) with jejunum vs. colon (11). These refinements collectively address the “double jeopardy” of GCC surgery: oncologic radicality vs. reoperative morbidity.

Despite reoperative complexity, no unplanned reoperations were required during the index hospitalization. Mean operative time of 384±129 minutes and median blood loss of 100 mL (IQR 100–150 mL), aligning with reported metrics for complex upper gastrointestinal surgeries. For instance, laparoscopic D2 total gastrectomy reported a median operative time of 406 minutes and blood loss of 102 mL (Shinohara et al. 2009) (19), while esophagectomy with colonic interposition found a mean operative time of 530±88 minutes and median blood loss of 200 mL (Cao et al. 2023) (20).

R1 resection was observed in three patients. In two cases involving tumors proximal third of the gastric conduit, circumferential margin involvement was due to dense mediastinal adhesions and proximity to critical structures (the membranous part of the trachea and major vascular structures). Neither patient received adjuvant therapy, and both died from severe malnutrition without evidence of recurrence. While not directly cancer-related, the presence of positive margins combined with poor postoperative nutritional status likely contributed to their early deterioration. Importantly, their compromised condition prevented the administration of timely adjuvant therapy, potentially missing a window for intervention.

The third case involved a patient who underwent a distal gastrectomy, where the proximal transection margin appeared microscopically negative, but final pathology revealed microscopic residual tumor. This was likely due to submucosal tumor spread, which can extend beyond the visible tumor boundary in gastric adenocarcinoma. These cases highlight the technical challenges of achieving clear margins in re-operative anatomy, especially in areas constrained by adhesions or adjacent vital structures.

Importantly, both pT4 cases in our cohort were clinically staged as cT3 based on preoperative PET and CT imaging. Given the absence of overt invasion on imaging, upfront surgery was considered appropriate by the multidisciplinary team. However, the presence of circumferential margin (CRM) involvement and pathological T4 status highlights the limitations of preoperative staging in this population. These findings support the potential value of neoadjuvant therapy in select cases, even when imaging suggests resectable disease, particularly in the setting of nodal metastases.

Most GCC cases (70–80%) are diagnosed at advanced stages when symptoms manifest, contributing to poor prognosis (10,17). To help contextualize the survival outcomes, we reviewed the most relevant benchmark data available in the literature. For instance, population-based data from the Surveillance Epidemiology, and End Results (SEER) database indicate a 2-year survival of approximately 50–65% for patients undergoing de novo gastrectomy for stage II–III gastric cancer (21). Endoscopic resection of early-stage GCC has shown a 2-year survival of 69%, as reported by Toyoshima et al. in 2023 (11). In contrast, chemoradiation for unresectable GCC has yielded lower survival, with Yoon et al. reporting a 2-year rate of 22% (18). Our 59% 2-year-survival, therefore, appears consistent with resectable cancer outcomes, especially in surgically complex post-esophagectomy anatomy. These results reinforce the viability of surgery in appropriately selected GCC patients even within a complex reoperative context.

Limitations

This study has several limitations that warrant consideration. The small sample size of 17 patients, owing to the rarity of GCC, limits statistical power and generalizability. The retrospective design may introduce selection bias, as surgical decisions were based on tumor location, extent and intraoperative assessment rather than randomization. Additionally, the relatively younger median age of our cohort (66 years) despite a long interval post esophagectomy (84 months) suggests referral bias as our center is a tertiary institution where there were patients were preferentially referred for surgical management, potentially underrepresenting older or higher risk individuals treated non-operatively elsewhere. The lack of a control group further limits comparisons across treatment modalities. Additionally, the wide variation in follow-up duration, ranging from a median of 17 months to over 5 years, and wide confidence intervals in survival estimates require cautious interpretation.

While our center performs approximately 1,000 esophagectomies annually, most patients in this study were referrals from other institutions, often several years post-esophagectomy. Therefore, the cohort’s precise incidence of GCC is unknown. Nevertheless, the patients in this study will be monitored further to evaluate these long-term outcomes. The small and heterogeneous nature of the cohort also limited meaningful analysis of systemic therapy impact, and the inconsistent documentation of prior esophagectomy approach (open vs. minimally invasive) hindered its analysis. Finally, the altered anatomy in post-esophagectomy patients often limited the feasibility of EUS. This may have affected the preoperative staging accuracy and introduced the possibility of stage migration.

Conclusions

In conclusion, surgical resection for GCC appears to be a safe and feasible option in carefully selected patients who are not candidates for endoscopic treatment, with acceptable short-term morbidity and preliminary survival outcomes. These findings contribute to the limited evidence available for this rare condition and may support surgical decision-making in complex clinical scenarios.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-441/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-441/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-441/prf

Funding: This work was supported by Shanghai Hospital Development Center (SHDC2025CCS023 and SHDC22024225, to Z.L.) and National Clinical Key Specialty Construction Project (10000015Z155080000004, to Z.L.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-441/coif). Z.L. serves as an unpaid Associate Editor-in-Chief of Journal of Thoracic Disease from April 2024 to April 2025. Z.L. also reports that this work was supported by the Program of Shanghai Academic/Technology Research Leader (No. 22XD1402900) and the National Clinical Key Specialty Discipline Construction Project (No. 10000015Z155080000004). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Shanghai Chest Hospital (No. IS24164). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Shah MA, Altorki N, Patel P, et al. Improving outcomes in patients with oesophageal cancer. Nat Rev Clin Oncol 2023;20:390-407. [Crossref] [PubMed]
2. Johanna L, Farma JM. Primary Gastric Conduit Cancer 10 Years after Esophagectomy for Esophageal Adenocarcinoma. Sur Cas Stud Op Acc J 2018;1:SCSOAJ.MS.ID.116.
3. Lee GD, Kim YH, Choi SH, et al. Gastric conduit cancer after oesophagectomy for oesophageal cancer: incidence and clinical implications. Eur J Cardiothorac Surg 2014;45:899-903. [Crossref] [PubMed]
4. Khorobrykh T, Ivashov I, Spartak A, et al. Gastric Conduit Cancer following Ivor-Lewis Esophagectomy for Esophageal Adenocarcinoma: A Case Report and Literature Review. Case Rep Oncol 2023;16:1196-202. [Crossref] [PubMed]
5. Akita H, Doki Y, Ishikawa O, et al. Total removal of the posterior mediastinal gastric conduit due to gastric cancer after esophagectomy. J Surg Oncol 2004;85:204-8. [Crossref] [PubMed]
6. Urabe M, Haruta S, Tanaka M, et al. Management and outcomes of resectable gastric conduit cancer: a retrospective comparative study of 51 cases. Langenbecks Arch Surg 2021;406:1433-41. [Crossref] [PubMed]
7. World Medical Association Declaration of Helsinki. ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4. [Crossref] [PubMed]
8. Brierley JD, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours. Hoboken: John Wiley & Sons; 2017.
9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13. [Crossref] [PubMed]
10. Gentile D, Riva P, Da Roit A, et al. Gastric tube cancer after esophagectomy for cancer: a systematic review. Dis Esophagus 2019;32:doz049. [Crossref] [PubMed]
11. Toyoshima Y, Narumiya K, Kudo K, et al. Comparative analysis of the outcomes of gastrectomy vs. endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric tube cancer after esophagectomy. Glob Health Med 2023;5:40-6. [Crossref] [PubMed]
12. Nakanoko T, Morita M, Nakashima Y, et al. Nationwide survey of the follow-up practices for patients with esophageal carcinoma after radical treatment: historical changes and future perspectives in Japan. Esophagus 2022;19:69-76. [Crossref] [PubMed]
13. Dixon MF, Mapstone NP, Neville PM, et al. Bile reflux gastritis and intestinal metaplasia at the cardia. Gut 2002;51:351-5. [Crossref] [PubMed]
14. Strong MS, Incze J, Vaughan CW. Field cancerization in the aerodigestive tract--its etiology, manifestation, and significance. J Otolaryngol 1984;13:1-6.
15. Ota M, Morita M, Ikebe M, et al. Clinicopathological features and prognosis of gastric tube cancer after esophagectomy for esophageal cancer: a nationwide study in Japan. Esophagus 2022;19:384-92. [Crossref] [PubMed]
16. Meng ZW, Bishay K, Vaska M, et al. Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis. J Gastrointest Surg 2023;27:2628-39. [Crossref] [PubMed]
17. Sugiura T, Kato H, Tachimori Y, et al. Second primary carcinoma in the gastric tube constructed as an esophageal substitute after esophagectomy. J Am Coll Surg 2002;194:578-83. [Crossref] [PubMed]
18. Yoon YS, Kim HK, Choi YS, et al. Primary gastric cancer in an oesophageal gastric graft after oesophagectomy. Eur J Cardiothorac Surg 2011;40:1181-4. [Crossref] [PubMed]
19. Shinohara T, Kanaya S, Taniguchi K, et al. Laparoscopic total gastrectomy with D2 lymph node dissection for gastric cancer. Arch Surg 2009;144:1138-42. [Crossref] [PubMed]
20. Cao C, Liu F, Yu S, et al. Esophagocolonic OrVil Anastomosis After Minimally Invasive Esophagectomy. J Laparoendosc Adv Surg Tech A 2023;33:117-23. [Crossref] [PubMed]
21. National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Cancer Stat Fcts: Stomach Cancer. [Accessed May 15, 2025]. Available online: https://seer.cancer.gov/statfacts/html/stomach.html