Marcel André Schneider, Andrew Davies, Catherine O'Brien, Cara Baker, James Gossage, Jessie Elliott, Nicola Raftery, Rakesh Ahmed, Fredrik Klevebro, Magnus Nilsson, Nora Norén, Olga Meier Adamenko, Ewen Griffiths, William Butterworth, Hans Schlößer, Christiane Bruns, Eleni Tzitzili, Felix Nickel, Marius Kemper, Petro Zgurskyi, Misha Luyer, Tessa Geraedts, Luigi Bonavina, Alberto Aiolfi, Ines Gockel, René Thieme, Stefan Niebisch, Marko Kraljevic, Beat Müller, Lucien Cron, Felix Berlth, Alfio Milazzo, Bruno Sgromo, Holly Harris, Lucia Moletta, Michele Valmasoni, Mishal Hubka, Simone Giacopuzzi, Alice Collizzolli, Riccardo Rosati, Agnese Carresi, Silvia Battaglia, Stefano Santi, Monica Gualtierotti, Fabrizio Rebecchi, Lorenzo Viggiani d'Avalos, Manuel Pera, Enrique Biel, Arnulf Hölscher, Martin Hemmerich, Edward Cheong, Elke Van Daele, Hanne Vanommeslaeghe, Giulia Nezi, Bastiaan Klarenbeek, Peter Grimminger, Christian Alexander Gutschow, For The Restorant Working Group
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.