Revisional surgery for delayed gastric conduit emptying after esophagectomy: the RESTORANT project

Delayed gastric conduit emptying (DGCE) is a debilitating functional complication after esophagectomy. Because of a lack of large-scale outcome data, this project evaluated surgical revisional strategies for refractory DGCE within a recently published mechanism-informed classification system. REvisional Surgery for delayed gasTRic conduit emptying (RESTORANT) was a multicentric, retrospective cohort study including adult patients undergoing revisional surgery for DGCE from January 1, 2015, to December 31, 2024, across 26 high-volume centers that performed 11,807 esophagectomies during this period. Patients were eligible irrespective of the date of their index esophagectomy. Interventions were stratified into Class 1 (pylorus-related, C1), Class 2 (conduit-related, C2), and Class 3 (hiatus-related/paraconduit hernia, C3), with class assigned retrospectively according to the revisional procedure performed. The primary endpoint was reported symptom resolution. A total of 196 patients underwent 263 surgical interventions for DGCE. Sustained symptom relief was comparable across all classes: C1 (47.2%), C2 (58.2%), and C3 (63.9%; P = 0.165). For C1, pyloroplasty (47.6%) and Roux-en-Y diversion (46.7%) showed similar efficacy. In C2, conduit replacement (75.0%) and remodeling (61.3%) were significantly more effective than simple mobilization (50.0%; P = 0.035). For C3, paraconduit hernia repair achieved higher resolution than crural division (65.8% vs. 47.1%). The overall complication rate was 32.7%, with significantly higher major morbidity and mortality in C2 (20.0% and 3.6%) compared with C3 (13.4% and 1.7%) and C1 (16.7% and 2.8%, P = 0.047). Multivariable analysis identified no independent predictors of surgical success but was limited by heterogeneity and sample size. RESTORANT provides the first multicentric analysis of surgical DGCE repair. While symptom resolution is achievable across all classes, C2 interventions carry increased risks. These findings may help structure future prospective audits.