Requiring Multi-Steps During Minimally Invasive Surgery to Achieve Optimal Proximal Resection Margin for Siewert-Types II and III Esophagogastric Junctional Cancer

Taketo Matsunaga,Yukie Yoda,Akihiko Uchiyama,Hiromichi Iwasaki ,Hirokazu Noshirο

doi:10.31487/j.aco.2019.04.02

Abstract

Background: Transection of the esophagus at a cancer-negative proximal surgical margin and alimentary tract reconstruction through the hiatus during minimally invasive surgery (MIS) may be complicated and difficult in some patients with Siewert type II or III esophagogastric junctional cancer (EGJC). In this study, we retrospectively determined requiring multi-steps during MIS for Siewert types II and III EGJC. Study Design: Fifty-one consecutive patients with surgically treated Siewert type II or III EGJC were reviewed from July 2006 to October 2016. Five patients were excluded, and the remaining forty-six patients were divided into four groups based on the combination of laparoscopic and thoracoscopic surgical procedures performed, according to Siewert classification and TNM-staging: one-step surgery (n = 16), twostep surgery without novel transection of the esophagus (n = 8), two-step surgery with novel transection of the esophagus (n = 13), and three-step surgery (n = 9). Results: The esophagus was transected successfully with a cancer-free proximal margin in all but one patient. However, only 16 patients (35 %) were treated successfully by laparoscopic surgery alone, and the remaining 30 patients needed one or more additional steps to complete the anastomosis after transection of the esophagus according to the extent of esophageal invasion of the tumor. Conclusion: Multi-step procedures may be needed to achieve a cancer-negative proximal margin followed by alimentary reconstruction during MIS in patients with Siewert type II or III EGJC.

Highlights

The number of patients with esophageal or gastric cancer treated by minimally invasive surgery (MIS) using thoracoscopy, laparoscopy, or both has been increasing [1,2,3,4,5]
We retrospectively reviewed a consecutive series of patients with Siewert-type II or III esophagogastric junctional cancer (EGJC) who underwent MIS, with a focus on the complexity of surgical steps required to transect the esophagus with a cancer-negative proximal surgical margin and to reconstruct the alimentary tract after resection
Nine patients received three-step surgery because the esophagus at the proximal side needed to be transected at the middle portion of the thoracic esophagus, or the lymph node status needed to be determined in the mediastinum, as the lesions were spread relatively distant from the squamo-columnar junctional line or metastatic nodes were suspected preoperatively in the middle-upper mediastinum

Summary

Introduction

The number of patients with esophageal or gastric cancer treated by minimally invasive surgery (MIS) using thoracoscopy, laparoscopy, or both has been increasing [1,2,3,4,5]. In cases with EGJC or gastric cancer with long esophageal invasion, MIS procedures involving two or more-steps may be required to ensure transection of the esophagus with a cancer-negative proximal surgical margin and safe reconstruction of an alimentary tract [7, 18, 19]. We retrospectively reviewed a consecutive series of patients with Siewert-type II or III EGJC who underwent MIS, with a focus on the complexity of surgical steps required to transect the esophagus with a cancer-negative proximal surgical margin and to reconstruct the alimentary tract after resection. Transection of the esophagus at a cancer-negative proximal surgical margin and alimentary tract reconstruction through the hiatus during minimally invasive surgery (MIS) may be complicated and difficult in some patients with Siewert type II or III esophagogastric junctional cancer (EGJC).

Methods

Results

Conclusion