Surgical outcomes of laparoscopic transhiatal lower mediastinal lymphadenectomy for seiwert type II adenocarcinoma of the esophagogastric junction.

155 Background: Optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG-II) has not yet been determined, presumably due to complex anatomical structures and the limited number of reports regarding this aspect. The transhiatal approach is preferred in East Asia in cases with 30 mm or less esophageal invasion, and laparoscopic surgery is increasingly performed. However, the feasibility of the laparoscopic transhiatal approach for AEG-II is still unclear, and thus was investigated in this study. Methods: A total of 51 consecutive patients who underwent total/proximal gastrectomy with lower mediastinal lymphadenectomy by laparoscopic transhiatal approach between January 2008 and May 2018 were included. Patients with greater than 30 mm esophageal invasion, and those who received preoperative chemotherapy, were excluded. Results: The male/female ratio was 38:13, and the median age (range) was 69 (37-81) years. Total gastrectomy and proximal gastrectomy were performed in 10 and 41 patients, respectively. All surgeries were performed by experienced surgical teams. Median operation time and intra-operative blood loss were 300 (141-511) minutes and 21 (0-267) g, respectively. Pathological tumor depth was T2 or deeper in 28 patients (55%), and nodal status was negative in 20 patients (39%). Clavien-Dindo grade IIIa or higher complications were observed in eight patients (16%), which included two anastomotic leakages and one pancreas fistula, and the mortality rate was 0%. The 5-year overall survival rate of all patients was 97% with a median observational period of 30 months. Conclusions: Laparoscopic transhiatal approach with lower mediastinal lymphadenectomy seems to be a technically feasible procedure, provided an experienced surgical team performs the surgeries. However, oncological safety for advanced disease needs to be confirmed, considering that the proportion of advanced stage cancer included in this study was limited.

Laparoscopic Transhiatal Thoracic Duct Ligation for Chylothorax after Esophagectomy

In esophagectomy for thoracic esophageal cancer, chylothorax may develop at a certain frequency. For chylothorax, conservative treatment is selected first, but if it is not improved, thoracic duct (TD) ligation is considered. In general, transthoracic approach is chosen to reach the TD. However, it is sometimes difficult to identify the TD due to adhesion in the thoracic cavity. Hence, we selected a laparoscopic transhiatal approach to the TD. We introduce the procedure of our laparoscopic transhiatal TD ligation technique.