Endoscopic accessibility and conduit passage after retrosternal vs. posterior mediastinal gastric conduit reconstruction following McKeown esophagectomy: a retrospective cohort study.

BACKGROUND: The optimal route for gastric-conduit reconstruction after McKeown esophagectomy remains uncertain. Previous comparisons have focused primarily on anastomotic leakage and pulmonary morbidity, whereas postoperative endoscopic accessibility and clinically evident conduit-passage disturbance have been less well characterized. We compared retrosternal (RS) and posterior mediastinal (PM) reconstruction, focusing on these functional outcomes.

METHODS: This single-center retrospective cohort included 37 patients treated by the same surgical team between March 2025 and April 2026 (RS, n=14; PM, n=23). Upper gastrointestinal contrast assessment was generally performed at approximately 2 weeks and routine postoperative endoscopy at approximately 3 weeks, unless endoscopy was contraindicated or not feasible. Endoscopy time and route-related difficulty were evaluated at the examination level. Clinically evident passage disturbance, defined as dysphagia with retained food or impaired bolus transit requiring endoscopic confirmation or treatment, was evaluated at the patient level during 3 months of follow-up. Early and late delayed gastric conduit emptying (DGCE) and secondary perioperative outcomes were also assessed. All comparisons were unadjusted and exploratory.

RESULTS: Among examinations with recorded duration (13 RS and 24 PM), median endoscopy time was longer after RS reconstruction [14.00 (8.00, 17.00) vs. 7.50 (6.00, 11.00) minutes, P=0.01]. Route-related difficulty in scope advancement or incomplete anastomotic visualization was documented in four RS examinations and in none of the 24 completed PM examinations. Four RS patients developed clinically evident passage disturbance with dysphagia and retained food, compared with no PM patients (4/14 vs. 0/23, P=0.02). All four events were associated with anastomotic stricture; retained food was removed endoscopically, followed by dilation in three patients and stent placement in one, and all subsequently resumed oral intake. Anastomotic stricture occurred in 4/14 RS and 1/23 PM patients (P=0.057). No statistically detectable between-group differences were observed for early DGCE (1/14 vs. 1/23; P>0.99), late DGCE (2/14 vs. 0/23; P=0.14), or anastomotic leakage (1/14 vs. 2/23; P>0.99).

CONCLUSIONS: RS reconstruction was associated with longer examination-level endoscopy time and four stricture-related passage-disturbance events in this small cohort, whereas no statistically detectable route-related difference in DGCE was observed. These unadjusted findings are hypothesis-generating and do not establish the superiority of either route. Larger prospective studies incorporating standardized endoscopic assessment, route-geometry measures, validated dysphagia instruments, and longitudinal functional outcomes are warranted.