Abstract
Aim
To report a novel approach for tumours located at the gastro-oesophageal junction (GOJ) using a laparoscopic abdominal phase combined with a left thoracoabdominal approach.
Background and Methods
The standard left thoracoabdominal approach offers excellent exposure and access to GOJ and lower oesophagus. It also involves a single position for the procedure, shortening the operation time. The disadvantages are a large incision, dividing the costochondral junction, and a low level thoracotomy. Laparoscopic Left Thoracoabdominal Oesophagectomy (LLTA) is performed with the patient in the same right lateral decubitus position, but rolled away from the operator at 45xxx. allowing laparoscopic gastric mobilisation and lymphadenectomy. The thoracic phase uses an anterolateral left thoracotomy through the higher 5th intercostal space, giving a higher intrathoracic anastomosis, just below the aortic arch. No disruption of the costochondral junction is made. Consecutive patients treated for GOJ tumours with LLTA operated on during 2013-2019 were analysed and compared to national standards (NOGCA).
Results
This series of 70 consecutive patients had a mean age of 63 years. Median operation time was 235 minutes. Median inpatient hospital stay was 10 days (NOGCA 9 (11-17)). The majority were adenocarcinoma; predominantly located in the GOJ (Siewert Type1 (37.14%), Type2 (45.71%), Type3 (2.86%)); 90% of the tumours were T3 or T4. Postoperative morbidity was low (Clavien-Dindo 0 in 50% of the patients). The median number of total lymph nodes excised was 27.77 (NOGCA >15). Positive nodes were predominantly located in the lesser-curve (40%), Para-oesophageal 34.29%; Sub-carinal 2.86%. Positive circumferential resection margins (<1mm) were present in 28.57% of patients (NOGCA 25.1%). In-Hospital and 30 day mortality was 1.43% (NOGCA 2.7%). Recurrence after LLTA was 24.29% at a mean 371 days (local 5.7%, systemic 15.7%, mixed 2.86%).
Conclusion
This series demonstrates a novel, safe and reproducible left sided approach for cancer of the GOJ. There is good exposure at the hiatus, without the division of the costochondral junction and low thoracotomy.