The 4th Joint Session between JDDW-KDDW-TDDW2(JDDW)
Thu. November 5th   14:00 - 16:15   Room 9: Portopia Hotel Main Building Kairaku 3
JKT2-RS1
 Is minimal invasive surgery feasible for gastroesophageal junction tumor?
Masanori Tokunaga
Tokyo Medical and Dental University
Background: The incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing in Japan, and a current standard treatment for resectable AEG is gastrectomy with lower esophageal resection through the transhiatal approach. Minimally invasive surgery (MIS) for advanced gastric cancer is widely practiced, and the non-inferiority of MIS to the open approach was confirmed in patients with lower two-thirds gastric cancer in two Asian studies. However, the feasibility of MIS for AEG still remains unclear, and thus in this report, potential advantages and disadvantages of MIS for AEG are summarized and introduced.
Potential advantages: MIS for AEG can be performed with less bleeding and earlier recovery, as reported in previous studies comparing MIS with open surgery. Another potential advantage is that MIS will facilitate a better surgical field in the lower mediastinum which includes deep and narrow areas. In open surgery, surgeons’ hands and devices are obstacles to making the surgical field viewable for assistants, while in MIS, a laparoscopic camera can approach close to the surgical field, resulting in surgical field images which can be shared with the operator and assistants performing procedures like low anterior resection for rectal cancer. This can result in more meticulous surgery with fewer postoperative complications.
Potential disadvantages: MIS may result in slightly longer operation times than open approach. In addition, conflict among devices including laparoscopic cameras is one of the possible drawbacks, but this has been partially overcome by the advent of robotic surgery with articulated devices. However, lack of robust evidence which supports the superiority of MIS should be taken into account, and well-designed trials, ideally randomized controlled trials, are needed for MIS for AEG to be accepted more broadly.
Surgical procedure: The transhiatal approach is selected in cases with esophageal infiltration of 3cm or less. Lower mediastinal lymph node dissection is performed while exposing the pericardium, aorta, and both sides of the pleural membrane. The esophagus is transected under the guidance of intra-operative endoscopy. Overlap reconstruction is primarily selected for esophagojejunostomy, and the entry-hole is closed with either interrupted or running sutures.
Summary: MIS for AEG will be more widely accepted when newly developed devices, such as robots, are available to facilitate the procedures. We should commence planning clinical trials to demonstrate the superiority of MIS.
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