Department of Surgery, Faculty of Medicine, Saga University, Saga; and Department of Surgery, Kyushu Kouseinenkin Hospital,Kitakyushu, Japan
Background. Because surgery for esophagogastric junc-tional cancer (EGJC) occasionally requires a thoracotomyin addition to a laparotomy, surgery is associated withhigh mortality and morbidity rates. Therefore, minimallyinvasive surgery should be developed as an alternative toconventional open surgery.
Methods. We herein describe our first series of sevenpatients with EGJC who were treated by minimally-invasive surgery using thoracoscopy in addition to thelaparoscopic procedure. During the thoracoscopic proce-dures, transection of the esophagus was performed at thecancer-free portion with a dissection of lower mediasti-nal nodes and a side-to-side Roux-en-Y esophagojejunos-
Results. In the seven patients treated using thisprocedure, the mean total length of the operation was606 minutes and the mean number of retrieved lymphnodes was 58. No adverse events occurred intraope-ratively and no failure in the intrathoracic esophago-jejunostomy was observed, and favorable short-termresults were obtained.
Conclusions. The described procedure for the treat-ment of patients with EGJC is a minimally invasivealternative to conventional open surgery that lookspromising.
In recent decades, the frequency of adenocarcinoma inthe esophagogastric junction has increased [1, 2].
During surgery for esophagogastric junctional cancer(EGJC), a total gastrectomy or proximal gastrectomy isselected according to the extent of tumor infiltration tothe stomach and the status of lymph node metastasis.However, the transhiatal procedure alone for the medi-astinal side is complex due to the dissection of the lowermediastinal lymph nodes and a cancer-negative surgicalproximal margin of the esophagus [3–8]. Although theefficacy of a sufficient dissection of lower mediastinalnodes remains controversial in cases of advanced gastriccancer with esophageal invasion, a relatively high lymphnode metastasis rate has been reported [3–5, 9–12]. More-over, they are concerned that additional thoracotomyprocedures are associated with a high mortality andmorbidity rate [6, 10, 12].
An increasing number of patients with esophageal andgastric cancer have been treated by less invasive surgeryusing either thoracoscopy or laparoscopy [13–18]. How-ever, so far there has been no previous report regardingpurely thoracoscopic intrathoracic reconstruction of thealimentary tract after excision of EGJC. We herein de-scribe a totally thoracoscopic esophagojejunostomy afterthe abdominal procedures for 7 patients with EGJC.
Accepted for publication Aug 11, 2011.
Address correspondence to Dr Noshiro, Department of Surgery, Faculty
Patients and Methods
From June of 2006 to February of 2011, 7 patients (1female subject and 6 male subjects) had a diagnosis oflower esophageal cancer or advanced gastric cancer in-filtrating into the lower esophagus after thorough preop-erative assessments with the upper gastrointestinal se-ries, computed tomography, and an endoscopicexamination at either our hospital or affiliated hospital.Our surgical therapeutic strategy for EGJC, which in-cludes esophageal squamous cell carcinoma in the ab-dominal portion as well as adenocarcinoma of the Siew-ert types [19], is based on the location and staging of thetumor and thoracoscopic intrathoracic Roux-en-Y recon-struction was applied for the patients described below.Patients with tumors of the Siewert types 1or 2 who hadthe previous gastric surgery were treated by an abdom-inal approach, including total remnant gastrectomy withthe dissection of the perigastric lymph nodes and thenodes along the left gastric artery and the lower medias-tinal lymph nodes, as well as a Roux-en-Y esophagojeju-nostomy. Advanced gastric cancers invading less than 3cm into the esophagus belonging to Siewert types 2 or 3were treated by a transhiatal abdominal approach, in-cluding a total gastrectomy with the dissection of theperigastric lymph nodes, regional second tier-nodesalong the left gastric, common hepatic, splenic, and celiacarteries, and lower mediastinal lymph nodes, and aRoux-en-Y esophagojejunostomy. In patients belongingto the above 2 categories, whether transection of the
esophagus and creation of a laparoscopic Roux-en Y
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esophagojejunostomy are technically feasible depends notonly on the esophageal tumor length from the esophago-gastric line (z-line) but also on the existence of an esopha-geal hiatal hernia. If it is impossible to perform through anabdominal approach, thoracoscopic surgery represents analternative. In cases of advanced gastric cancers invadingover 3 cm into the esophagus that are classified into types 2and 3, a transthoracic and abdominal approach is adoptedto achieve adequate lower mediastinal lymph node dissec-tion and to obtain a safe surgical margin. Distant metastasis,multiorgan involvement, enlarged cervical lymph nodes,and suggestive paraaortic lymph node metastasis on com-puted tomography or 18F-fluorodeoxyglucose-positronemission tomography scan findings were considered indi-cations of incurable disease. The contraindications for athoracoscopic procedure were the following: tumor infil-trating other structures; impaired circulatory or pulmonaryfunction prohibiting single-lung ventilation; a concomitantserious medical disorder such as severe diabetes mellitus,chronic renal failure, or liver cirrhosis; and patient refusal toundergo thoracoscopic surgery. The tumors were stagedaccording to the seventh edition of the tumor, nodes,metastasis classification system. The 7 patients were fullyinvolved in the decision-making process and informedconsent was obtained from all patients.
Surgical ProceduresAt least 2 steps are necessary for the present procedure.Ideally, we start the procedure laparoscopically, includingthe transhiatal dissection and transection of the esophagus,and then we proceed with thoracoscopy. However, if weanticipate a difficult transhiatal transection of the esopha-gus then the first thoracoscopic procedure includes a lowermediastinal lymph node dissection and transection of theesophagus at the cancer-free portion. The intrathoracicesophagojejunostomy is performed during a second thora-coscopic procedure after the abdominal procedure. Thedetails of our thoracoscopic and laparoscopic or laparotomyprocedures are described below.
Abdominal ProceduresMobilization of the stomach and lymph node dissectionwere performed in the same manner of laparoscopicgastrectomy as previously reported (Fig 1) [15–17]. Theesophagus was isolated from the esophageal hiatus alongthe crus of the diaphragm toward the mediastinum. Thedissection of the supradiaphragmatic and lower medias-tinal nodes was achieved above the diaphragm and alongthe descending aorta and bilateral pulmonary ligamentsas far as transhiatally possible. The esophagus could beisolated about 5-cm length together with the dissectednodes. If the esophagus could be transhiatally transectedusing an endoscopic linear stapler (ETS 45-4.5; EthiconEndo-Surgery, Cincinnati, OH), the excised specimenwas placed in a plastic bag and removed through thesupraumbilical port site extended transumbilical to 4 to 5cm and immediately the margin was confirmed to becancer negative by a pathologic examination. The jeju-num 20 to 30 cm distal to the ligament of Treitz was
prepared as a Roux limb after total gastrectomy. The
jejunum was transected with an endoscopic linear stapler(ETS 45-2.5; Ethicon Endo-Surgery) and the mesente-rium, including the arcade of the jejunal vessels, wasdivided. The jejunal vessels could be identified grossly bytheir contour and pulsation, and the mesenterium had tobe divided carefully to avoid the injury of the vessels.First, the serosa of the mesenterium was cut after thedivision of the arcade of the jejunal vessels. Then, the fattissue of the mesenterium was divided by a short pitchtoward the bifurcation of the jejunal vessels. In addition,one or more jejunal arteries and veins originating fromthe superior mesenteric artery and vein were divided toenable the jejunal limb to be moved to the residualesophagus up to the carina without any tension (Fig 2).To cover over the extraverted stump of the jejunum toavoid a formation of the enteropulmonary fistula in thethorax, several seromuscular sutures were added to thestump. The jejunal limb was placed in a vinyl bag andbrought up through the retrocolic route naturally withoutany torsion. A jejunojejunostomy of the Roux-en-Y limbafter the gastrectomy was made in the same manner aspreviously reported [17]. The 2 appropriate points of theRoux-en-Y jejunal limb were fixed with the esophageal
Fig 1. Sites of the trocars for laparoscopic surgery. In the abdo-men, a 12-mm blunt trocar is inserted above the umbilicus. Another4 trocars are inserted into the bilateral subcostal sites and the flankabdominal sites.
hiatus and the transverse mesocolon by suturing to
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prevent the development of a sliding hiatal hernia. Nofeeding jejunostomy tube was placed. Two drains wereinserted toward the lower mediastinum through thehiatus and in the space below the left diaphragm.
In patients with a history of a distal gastrectomy,mobilization of the gastric remnant and lymph nodedissection were performed under a conventional celiot-
Fig 2. Preparation of the jejunal limb for Roux-en-Y reconstruc-tion. One or more jejunal arteries and veins originating from thesuperior mesenteric artery and vein should be divided to enable thejejunal limb to be moved to the residual esophagus without anytension.
Fig 3. Sites of the 4 trocars during the tho-racoscopic procedures. In the chest, a 12-mmblunt trocar is inserted in the fifth intercostalspace (ICS) on the posterior axillary line. An-other 3 trocars are inserted under thoraco-scopic control: a 12-mm trocar in the sixthICS on the scapular angle line, a 12-mm tro-car in the eighth ICS behind the posterior ax-illary line, and a 12-mm trocar in the ninthICS on the scapular angle line for the thora-coscope. Arabic numerals indicate the numberof the ICS. (MA � midaxillary line; PA �posterior axillary line.)
omy, and the other procedures were essentially the sameas the laparoscopic procedures described above.
Thoracoscopic Procedures in a Prone PositionOur actual procedures were basically similar to thethoracoscopic procedures on the right side for commonthoracic esophageal cancer except for the port sites (Fig 3)14, 20]. The right thoracoscopic approach was moreuitable than the left because the esophagojejunostomyas created around the subcarina. The thoracoscopicrocedures were performed with the patient in the proneosition, beginning December 2007, because of its noteduperiority with regard to the surgical view and itsechnical feasibility [20]. If the esophagus could not beransected during the abdominal procedure, the middlesophagus was mobilized circumferentially and thesophagus was divided at the appropriate portion belowhe arch of the azygos vein by linear stapling to facilitateymph node dissection on the left aspect of the esopha-us. If the first thoracoscopic procedure included only aransection of the esophagus and dissection of lymphodes, the patient was then placed in the supine positionnd underwent an abdominal procedure. Finally, in-rathoracic esophagojejunostomy was created during aecond thoracoscopic procedure. The esophageal hiatusf the diaphragm was explored and the jejunal stump ofhe Roux-en-Y limb could be easily determined.
Intrathoracic EsophagojejunostomyThe jejunal limb was brought up carefully until a suffi-cient length could be obtained for esophagojejunostomy.Thereafter, the jejunal limb conduit was rotated from thedorsal side to allow the antimesenteric side of the jeju-num to be explored in the anterior face for the anasto-motic procedure because the mesenteric side of thejejunum had been originally placed in the anterior face. Asmall incision was made on the left side of the esophageal
ataturoc(
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stump and the antimesenteric side of the Roux jejunal limb5 cm from the stump to make a side-to-side anastomosis
Fig 4. Intrathoracic side-to-side esophagojejunostomy using alinear stapler. (A) A small incision is made on the left side of theesophageal stump and the antimesenteric side of the Roux jejunallimb, 5 cm from the stump, to make a side-to-side anastomosis. Sta-pling is between the remnant esophagus and the antimesenteric sideof the jejunum. A V-shaped anastomosis is created. (B) The commonchannel for insertion of a linear stapler was closed by handsuturing.
(Fig 4A). The small incision on the jejunum must be longi-
tudinally made to prevent diminishing the size of the outletof the anastomosis after closure of the common incision forinsertion of the stapler. A 45-mm stapler (ETS 45-3.5) wasinserted through the eighth or ninth intercostal space port.Each jaw of the stapler was introduced into each incision(Fig 4A). The left wall of the esophageal remnant and thentimesenteric side of the jejunum were approximated, andhe stapler was closed and fired. Consequently, a V-shapednastomosis was created. The common incision was closedransverse by interrupted or continuous hand suturingsing PDSII 4-0 (Ethicon, Cincinnati, OH) (Fig 4B). Theemaining extraverted stump of the esophagus was coveredver by suturing. After the thoracoscopic procedures wereompleted, a single 28-Fr chest tube or a 24-Fr Blake drainEthicon, Somerville, NJ) was inserted.
Results
All 7 patients underwent entirely thoracoscopic procedureswithout any minithoracotomy incision or conversion to anytype of thoracotomy. The summarized characteristics andsurgical results of the 7 patients are listed in Tables 1 to 3.Thoracoscopic procedures had been performed in the leftlateral-decubitus position with the initial 2 patients beforethe procedure in the prone position was introduced. Theprocedures using thoracoscopy were combined with con-ventional laparotomy in 3 patients with the Siewert types 1and 2 because they had previously undergone a distalgastrectomy. For the other 4 patients, the procedures usingthoracoscopy were associated with the laparoscopic ab-dominal procedures to minimize the surgical invasiveness.In 4 patients with the Siewert type 1 or 2 and one Siewerttype 3 patient with greater than 3-cm esophageal invasion,a thoracoscopic procedure was advanced. Patient 2 had toundergo a 4-step procedure because the introduced jejunallimb was too long in the thorax and bent markedly evenafter the creation of the esophagojejunostomy, and thejejunal limb had to be refixed during an additional abdom-inal procedure.
Surgical outcomes are listed in Tables 2 and 3. Mortal-ity was not present. The lengths of the operations weretoo long because of the need for 2-step, or more, stepprocedures and the complexity of the procedures. Theyincluded the time required for positional changes, whichtook at least 20 to 30 minutes to set up the patient ineither position. In 2 patients (Nos. 3 and 6), it also took anadditional 1 or 2 hours to release the dense and broadpleural adhesion during the first thoracoscopic proce-dure. In spite of the long operation times, the estimatedblood losses were very low and none of the patientsrequired any type of blood transfusion during surgery.None of the 7 patients had any intraoperative complica-tions, and the endotracheal tube was removed at the endof the operation in all patients. The patients left theintensive care unit on the day after surgery and receivedprophylactic broad-spectrum antibiotics for 48 hours. Thetime to the first ambulation was within 2 days in all patients.We confirmed there was no presence of leakage and therewas good passage of the esophagojejunostomy by a gastro-
graffin swallowing examination in all patients. The time to
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resuming oral intake was 4 to 6 days in all patients exceptfor 2; one was a patient (No. 6) who underwent a reopera-tion for a rupture of the duodenal stump due to pancreaticfistula. No residual cancer cells on the surgical marginswere observed in the excised specimens (R0) and the meanproximal surgical margin from the esophageal tumor was3.7 cm (ranging from 2.0 to 6.5 cm). After a mean observa-tion period of 26 months all patients were alive, but relapseof the disease was observed in 2 patients; one (No. 2) hadlymph node metastasis at the splenic hilum and the other(No. 5) had paraaortic lymph node metastasis with perito-neal dissemination.
Comment
In several previous reports [3–6], 7% to 37% of patientswith advanced gastric cancer invading the lower esoph-agus had metastasized lymph nodes in the lower medi-astinum. Although some researchers advocate that anadditional thoracotomy approach has no survival benefitfor the Siewert type 2 and 3 tumors if the length ofesophageal invasion is 3 cm or less [6], others suggestthat curative resection of tumors invading the esophagusover 3 cm should be accompanied with lower mediastinallymph node dissection [21]. If less invasive surgery couldbe designed, it might be extremely difficult for EGJC toachieve reconstruction for an alimentary tract by a lapa-roscopic approach alone because the lower esophagus istoo shortened when the esophagus is transected at an
Table 1. Patient Characteristics
PatientNo. Gender
Age(Years)
SiewertTypea
M 75 Type 2M 54 Type 2F 76 Type 3M 80 Type 2M 65 Type 3M 69 Type 1M 69 Type 3
a Siewert classification was applied to squamous cell carcinoma as well a
� female; M � male; TNM � tumor, nodes, metastasis.
a Position of patients during the thoracic procedure. bParentheses show
A � abdominal procedure; LLDP � left lateral decubitus; PP � prone
appropriate portion of cancer negative tissue. If a patienthas a serious hiatal hernia, then the required proceduresare more complicated. Even in such a patient, thoraco-scopic surgery allowed us to perform the feasible andsafe reconstruction of an alimentary tract as well asmediastinal lymph node dissection in the thorax.
Although the present intrathoracic side-to-side esoph-agojejunostomy is essentially based on the procedureperformed intraabdominally after laparoscopic total gas-trectomy [22, 23], there are several important issues tomake thoracoscopic intrathoracic esophagojejunostomymore feasible while ensuring its safety. First, the transec-tion of the esophagus should be performed with a can-cer-negative margin. If it cannot be achieved by anabdominal procedure due to the location of the tumors orthe presence of a severe hiatal hernia, the transection ofthe esophagus should be performed under thoracoscopybefore an abdominal procedure. At that time, at least 3steps are required during less-invasive surgery. Second,the preparation of the jejunal limb for reconstructionshould be accompanied by the division of one or morejejunal arteries and veins to create a Roux-en-Y limb longenough to reach over the esophageal stump. Third, anappropriate portion of the jejunal limb should be fixed atthe transverse mesocolon and the transverse colon shouldalso be fixed at the hiatus to prevent the development of asliding hiatal hernia. Next, the incision made for the endo-scopic linear stapler should be closed transverse by inter-rupted or continuous hand suturing so as to create a wide
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anastomosis. Finally, some extraverted esophageal and in-testinal stumps in the thorax should be covered by suturingto prevent formation of pulmonary fistulas.
A low estimate blood loss, a short first ambulatory time,early resumed oral intake, no incidence of anastomotic failure,and a favorable short-term survival benefit were shown in ourseries. Aspiration pneumonia was observed in one elderlypatient, and was thought to be distinct from postoperativerespiratory complications. Persistent pleural effusion afterpleural adhesiolysis seems to be unavoidable. A rupture of theduodenal stump, resulting from pancreatic fistula, happenedin a patient with a laparotomic procedure due to a previousdistal gastrectomy. Postoperative complications happenedmainly in the patients with conventional laparotomy. Anasto-motic leakage was not observed in any of the patients, and theincidence of respiratory complications was minimal in thisseries. The complications we observed were related to thegastrectomy and lymph node dissection, and were not unex-pected. We emphasize that we observed no complicationsresulting from our minimally invasive approach. Consideringthese results, we may expect that this thoracoscopic proce-dure, combined with the laparoscopic procedure, will be lessinvasive than conventional procedures.
Conventionally, the thoracoscopic procedure for the treat-ment of esophageal cancer is most commonly performedwhen the patient is in the left lateral-decubitus position. In thethoracic portion of the procedure performed in the proneposition, increased operative exposure and improved surgeonergonomics allow surgeons to perform the meticulous dissec-tion of mediastinal lymph nodes and the complicated suturingin the thorax [20]. With superb views, nodes above the dia-phragm and along the left pulmonary ligament can be suffi-ciently dissected. It is our impression that during surgery thedissection of these portions by the prone approach might bemuch more extensive than those by the thoracoscopic proce-dure in the left lateral-decubitus position, or any conventionalopen procedure. In thoracoscopic surgery in the lateral-decubitus position, eye-hand coordination could not be ob-tained smoothly if a scope-holding assistant does not workcorrectly. The prone position could ameliorate thisdisadvantage.
The operative time in our initial experience with thepresent procedure was longer. Although the presentprocedure requires a high degree of technical skill, we
considered that one of the most time-consuming steps
was one or more positional changes of the patients; ittook 20 to 30 minutes to set up a surgical positionbetween the supine and a prone position. Another time-consuming step was the lymph node dissection aroundthe pancreatic body and tail at the splenic hilum, whichwas a meticulous and burdensome procedure becausethe formation of pancreatic fistula should be avoided. Wemust therefore solve these problems in the future.
In conclusion, we herein described our technique forperforming minimally invasive surgery using thoracoscopyfor EGJC. This procedure was preliminary but successfullyperformed in 7 patients. We expect this procedure to reducethe degree of invasiveness in patients with EGJC requiringintrathoracic esophagojejunal anastomosis.
References
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2. Pera M, Cameron AJ, Trastek VF, Carpenter HA, Zinsmeis-ter AR. Increasing incidence of adenocarcinoma of theesophagus and esophagogastric junction. Gastroenterology1993;104:510–3.
3. Clark GW, Peters JH, Ireland AP, et al. Nodal metastasis andsites of recurrence after en bloc esophagectomy for adeno-carcinoma. Ann Thorac Surg 1994;58:646–54.
4. Husemann B. Cardia carcinoma considered as a distinctclinical entity. Br J Surg 1989;76:136–9.
5. Kodama I, Kofuji K, Yano S, et al. Lymph node metastasisand lymphadenectomy for carcinoma in the gastric cardia:clinical experience. Int Surg 1998;83:205–9.
6. Sasako M, Sano T, Yamamoto S, et al. Left thoracoabdominalapproach versus abdominal-transhiatal approach for gastriccancer of the cardia or subcardia: a randomised controlledtrial. Lancet Oncol 2006;7:644–51.
7. Ito H, Clancy TE, Osteen RT, et al. Adenocarcinoma of thegastric cardia: what is the optimal surgical approach? J AmColl Surg 2004;199:880–6.
8. Wayman J, Dresner SM, Raimes SA, Griffin SM. Transhiatalapproach to total gastrectomy for adenocarcinoma of thegastric cardia. Br J Surg 1999;86:536–40.
9. Kawaura Y, Mori Y, Nakajima H, Iwa T. Total gastrectomywith left oblique abdominothoracic approach for gastriccancer involving the esophagus. Arch Surg 1988;123:514–8.
10. Maruyama K, Sasako M, Kinoshita T, Sano T, Katai H.Surgical treatment for gastric cancer: the Japanese approach.
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29 51 alive11 41 alivea
26 33 alive47 19 alive14 23 alivea
68 15 alive19 2 alive
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11. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph nodemetastasis and surgical management of gastric cancer invad-ing the esophagus. Hepatogastroenterology 1995;42:37–42.
12. Hulscher JB, van Sandick JW, de Boer AG, et al. Extendedtransthoracic resection compared with limited transhiatalresection for adenocarcinoma of the esophagus. N EnglJ Med 2002;347:1662–9.
13. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al.Minimally invasive esophagectomy: outcomes in 222 pa-tients. Ann Surg 2003;238:486–95.
14. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Kojima M,Tanaka M. Minimally invasive radical esophagectomy foresophageal cancer. Esophagus 2007;4:59–65.
15. Shimizu S, Noshiro H, Nagai E, Uchiyama A, Tanaka M.Laparoscopic gastric surgery in a Japanese institution: anal-ysis of the initial 100 procedures. J Am Coll Surg 2003;197:372–8.
16. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Tanaka M.Laparoscopically assisted distal gastrectomy with standardradical lymph node dissection for gastric cancer. Surg En-dosc 2005;19:1592–6.
17. Shinohara T, Kanaya S, Taniguchi K, Fujita T, Yanaga K,Uyama I. Laparoscopic total gastrectomy with D2 lymph
intrathoracic esophagojejunostomy is an excellent option
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18. Taguchi S, Osugi H, Higashino M, et al. Comparison ofthree-field esophagectomy for esophageal cancer incorpo-rating open or thoracoscopic thoracotomy. Surg Endosc2003;17:1445–50.
19. Siewert JR, Stein HJ. Carcinoma of the cardia: carcinoma ofthe gastroesophageal junction-classification, pathology andextent of resection. Dis Esoph 1996;9:173–82.
20. Noshiro H, Iwasak T, Kobayashi K, et al. Lymphadenectomyalong the left recurrent laryngeal nerve by minimally inva-sive esophagectomy in the prone position for thoracicesophageal cancer. Surg Endosc 2010;24:2965–73.
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INVITED COMMENTARY
Dr Noshiro and colleagues [1] have very elegantly de-scribed a minimally invasive technique for resecting ade-nocarcinoma of the gastroesophageal junction (GEJ) andperforming an intrathoracic Roux-en-Y esophagojejunos-tomy. The key points of their technique are an extendedlymphadenectomy, preparation of a long Roux-en-Y limbwith transection of one or two jejunal vascular branches,and a beautifully simple intrathoracic side-to-side anasto-mosis. Their technique is undoubtedly a major advance inthe minimally invasive resection of GEJ tumors. Thesesurgeons are to be commended for a major technical featwith excellent short-term and midterm outcomes. Impor-tantly, their report also draws attention to an approachforgotten among many North American thoracic surgeons.
How could this procedure evolve to become morewidely accepted in our surgical community?
First, a simplification of the approach could turn it into amore palatable venture. Could this minimally invasive esoph-agectomy be done in most patients in the modified rightlateral decubitus position that is the standard position for a leftthoracoabdominal incision? I believe the answer is “yes.”The esophagus can be mobilized en bloc with surroundingsoft tissue and subcarinal lymph nodes via a left thoracos-copy in the modified right lateral decubitus position. Left-ward rotation of the operating table allows full access to theabdominal wall for laparoscopy or midline laparotomy. Thecombination of a single position with Dr Noshiro’s elegantanastomotic technique could facilitate the procedure andshorten operative time. In addition, this approach allowsthe surgeon to visualize the Roux-en-Y limb at all times toavoid axial rotation and redundancy, and to easily convertto a left thoracotomy, laparotomy, or left thoracoabdominalincision if needed.
Second, we need to evaluate the role of this operationin cancer of the GEJ. An esophageal reconstruction with
if tumor characteristics or other factors preclude the useof a gastric conduit. The esophagojejunal anastomosiscan be made anywhere between the level of the inferiorpulmonary vein and the carina. The next question iswhether this type of esophagectomy and reconstructionis oncologically and functionally comparable to esopha-gogastric reconstruction in patients with a viable gastricconduit. The mean length of the proximal margin ofresection (3.7 cm ex situ), and the extent of the lymph-adenectomy (a mean of 56 lymph nodes removed) wouldsuggest that this procedure is oncologically appropriatefor many patients with adenocarcinoma of the GEJ. Fromthe functional perspective, it is currently impossible todetermine how the postoperative course and quality oflife would contrast for patients undergoing an intratho-racic esophagojejunostomy and those with an intratho-racic esophagogastrostomy. In an era of rapid rise ofadenocarcinomas of the GEJ, we should reacquaint our-selves with this procedure and consider a critical ap-praisal of our surgical approach to these patients.
I congratulate Dr Noshiro and his team for theirgroundbreaking, minimally invasive technique foresophagogastrectomy.
Rafael Andrade, MD
Division of Thoracic and Foregut SurgeryUniversity of Minnesota420 Delaware St SE, MMC 207Minneapolis, MN 55455e-mail: [email protected]
Reference
1. Noshiro H, Miyasaka Y, Akashi M, Iwasaki H, Ikeda O,Uchiyama A. Minimally invasive esophagogastrectomy for
esophagogastric junctional cancer. Ann Thorac Surg 2012;93:214–20.
