The 7th Joint Session between JDDW-KDDW-TDDW2(JDDW)
Thu. November 2nd   14:00 - 17:00   Room 9: Portopia Hotel Main Building Kairaku 3
Minimally invasive surgery for gastroesophageal junction adenocarcinoma
Jin-Jo Kim
Department of Surgery, The Catholic University of Korea College of Medicine
Gastroesophageal junctional cancer (GEJc) is defined as adenocarcinoma with an epicenter within 5 cm of the GEJ and extending into the esophagus. The incidence of GEJc has increased substantially in the past few decades, even in Eastern countries. GEJc is usually classified into 3 categories according to the Siewert system, which is based on the location of the epicenter of the tumor. Among these, Siewert type II tumors, located 1 cm above to 2 cm below the GEJ, represent true carcinoma of the GEJ.
According to the recent prospective trial in Japan, lower mediastinal lymph node dissection (LND) should be performed when the length of esophageal invasion is 2cm or more. If the length is more than 4cm middle and upper mediastinal LND should be performed, together. In the former case, Japanese researchers recommend to perform number 110 lymph node (LN) only. However, the anatomical landmark among the lower mediastinal LNs (No. 110, 111 and 112) is vague and it is difficult to differentiate one from the others. In my opinion, it would be easier and better to dissect the lower mediastinal LN as a whole. Moreover, systematic lower mediastinal LND would offer a clearer surgical view in later anastomosis in the lower mediastinum.
Recent laparoscopic transhiatal approach has some advantages over the open counterpart. Surgical view and instrumentation are much better in laparoscopic approach. I think this approach will have a promising future in this field.
In order to perform laparoscopic transhital LND, mobilization of Lt. lateral section of liver is essential to obtain a good surgical view. After full mobilization of Lt. lateral section, it is folded toward right side through a hole made in falciform ligament. An anterior midline incision is made on the diaphragm and the hiatal opening is widely opened. Lower mediastinal LND is performed through this hole. First, supradiaphragmatic LN (No. 111) is dissected and bilateral pulmonary ligaments (No. 112pul) and anterior side of the descending aorta (No. 112aoA) are dissected to the level of inferior pulmonary vein. After lower miediastinal LND, the esophagus is cut at the level of 2cm above the upper border of the tumor and the proximal stomach and upper abdominal LNs including No. 7, 8a, 9, 11p, 19 and 20 are resected. And then esophagogastrostomy using double flap technique is proceeded in the lower mediastinum.
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