Reconstruction After Proximal Gastrectomy for Adenocarcinoma of the Esophagogastric Junction: Current Evidence, Comparative Outcomes, and Future Perspectives

Objectives: The incidence of distal gastric cancer has declined worldwide owing to successful Helicobacter pylori eradication and improvements in environmental and dietary factors. In contrast, adenocarcinoma of the esophagogastric junction (AEG) and proximal gastric cancer have become increasingly prevalent, creating a growing need for function-preserving surgical approaches. Proximal gastrectomy has emerged as an attractive alternative to total gastrectomy because of its potential advantages in nutritional preservation and postoperative quality of life. However, concerns regarding postoperative reflux esophagitis have historically limited its widespread adoption. This review aimed to summarize the evolution of reconstruction after proximal gastrectomy and evaluate the advantages, limitations, and clinical outcomes of contemporary reconstruction techniques. Methods: A narrative review of the current literature was performed, focusing on reconstruction strategies following proximal gastrectomy. Major contemporary techniques, including double-tract reconstruction (DTR), double-flap reconstruction (DFT; Kamikawa method), side-overlap fundoplication by Yamashita (SOFY), and Toupet-like fundoplication reconstruction, were reviewed. Comparative evidence regarding reflux control, nutritional outcomes, operative complexity, anastomotic complications, and postoperative quality of life was examined. Results: Substantial advances in reconstructive techniques have significantly improved functional outcomes after proximal gastrectomy. DTR provides reliable reflux prevention, reproducibility, and broad applicability in minimally invasive surgery. DFT achieves excellent anti-reflux efficacy while preserving physiological food passage through the remnant stomach. SOFY offers favorable functional outcomes with reduced technical complexity and is particularly suited to laparoscopic and robotic surgery. Toupet-like reconstruction represents a promising alternative with encouraging early clinical results. Comparative studies indicate that all contemporary anti-reflux reconstruction methods substantially reduce reflux esophagitis compared with conventional esophagogastrostomy. Although each technique demonstrates specific advantages and limitations, no single reconstruction method has consistently shown superiority across all clinically relevant outcomes, including reflux prevention, nutritional preservation, operative complexity, and quality of life. Conclusions: Modern reconstruction techniques have expanded the role of proximal gastrectomy as a function-preserving alternative to total gastrectomy for proximal gastric cancer and AEG. Current evidence suggests that DTR, DFT, SOFY, and Toupet-like reconstruction can all achieve satisfactory oncological and functional outcomes when appropriately applied. Rather than identifying a universally superior procedure, contemporary practice should emphasize individualized reconstruction based on patient characteristics, surgeon expertise, and institutional experience. Future advances in robotic surgery, perioperative care, and standardized outcome assessment are expected to further optimize long-term outcomes following proximal gastrectomy.