Robotic Ivor Lewis esophagectomy with lymphadenectomy and two-layer hand-sewn thoracic esophagogastrostomy for locally advanced Siewert type II/III gastroesophageal junction adenocarcinoma following neoadjuvant FLOT chemotherapy with durvalumab.

Pre-treatment staging laparoscopy with peritoneal washings confirmed the absence of occult metastatic disease, allowing the patient to proceed with perioperative systemic therapy based on the MATTERHORN trial regimen. Molecular profiling demonstrated microsatellite-stable disease with low tumor mutational burden (4 muts/Mb) and genomic alterations including CCND1, FGF19, FGF3, FGF4, FLT3, KRAS, and MYC amplifications with TP53 mutation (R282W) and no ERBB2 amplification.

Restaging evaluation demonstrated a favorable treatment response with reduction in tumor size on cross-sectional imaging and marked biochemical response, with CEA decreasing from 57.7 ng/mL to 4.1 ng/mL during neoadjuvant therapy.

The patient subsequently underwent robotic staging laparoscopy, lymphadenectomy, and minimally invasive Ivor Lewis esophagectomy. The operation included mobilization of the stomach with preservation of the right gastroepiploic arcade, division of the left gastric vessels, creation of a narrow gastric conduit, and mediastinal esophageal dissection with paraesophageal and subcarinal lymphadenectomy. A two-layer robotic hand-sewn esophagogastric anastomosis was constructed within the thoracic cavity following conduit perfusion assessment using indocyanine green fluorescence angiography.

Final pathology demonstrated residual moderately differentiated adenocarcinoma of the gastroesophageal junction measuring 2.2 cm with near-complete treatment response, negative margins, and metastatic carcinoma in 4 of 24 lymph nodes (ypT3N2).

The patient recovered without major complications, demonstrated no anastomotic leak on postoperative contrast esophagram, and was discharged home on postoperative day four on a full liquid diet. Systemic therapy was reinitiated five weeks following surgery as part of the perioperative treatment strategy.