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Oo et al. Mini-invasive Surg 2019;3:13 I http://dx.doi.org/10.20517/2574-1225.2019.02 Page 5 of 9

pulmonary complications and chylothorax. Although median overall, disease-free, and quality-adjusted
survival did not differ statistically between the groups, there was a trend toward improved long-term

survival at five years with the extended transthoracic approach.In the follow-up study on 5 year survival,
there was no significant overall survival benefit for either approach (36% in TTE vs. 34% in THE, P =
[43]
0.71 . However, extended TTE for type I esophageal adenocarcinoma showed a trend towards better
5-year survival (51% vs. 37%, P = 0.33). Moreover, patients with a limited number of positive lymph nodes
in the resection specimen seem to benefit from an extended transthoracic esophagectomy.

In the Japanese JCOG 9502 trial, patients with Siewert II and III cancers were assigned to either transhiatal
[42]
approach (TH) or left thoracoabdominal approach (LTA) . TH consisted of a total gastrectomy with D2
lymphadenectomy (including splenectomy) via a laparotomy. Thoracotomy on either side was allowed to
achieve a complete (R0) resection only when the proximal surgical margin was positive (determined either
macroscopically or microscopically by frozen section) and no further transhiatal oesophageal resection
was possible. In LTA group, a thorough mediastinal nodal dissection below the left inferior pulmonary
vein was undertaken with oesophagectomy of sufficient length. The trial was closed prematurely as the
planned interim analysis concluded that the LTA approach was associated with higher morbidity and
mortality including postoperative complications such as pulmonary complications; 49% vs. 34%, P = 0.06)
and in-hospital mortality (4% vs. 0%, P = 0.25). Although statistically insignificant, both 5 years (38% vs. 52%)
[44]
and 10 years survival (24% vs. 37%) were found to be lower with LTA group .
Complete R0 resection of GEJ tumours is key to achieving good survival outcomes. Systematic review and
meta-analysis of fourteen studies involving 2433 patients with oesophageal cancer who had undergone
oesophagectomy showed that circumferential resection margin (CRM) involvement was associated with
[45]
significantly higher 5-year mortality rate (OR 2.05, 95%CI: 1.41-2.99; P < 0.001) .

There are few options for reconstruction after resection of GEJ tumours. For Type II and Type III
tumours, after extended total gastrectomy and distal esophagectomy the reconstruction is usually done
with Roux-En-Y esophago-jejunostomy. For Type I tumours, combined transabdominal and transthroaic
approach is required to perform enbloc eosophagectomy and proximal gastrectomy together with 2 field
lymphadenectomy. The other available option is a left throacoabdominal approach with intrathoracic
anastomosis know as Sweet esophagectomy. The stomach is used as a conduit to perform intrathoracic
oesophagogastrostomy for reconstruction. In some patients, if gastric conduit is unsuitable, due to previous
surgery, the jejunum and colon are both possible conduit options.

Open versus minimally invasive approach
Evidence suggests that transthoracic approach with radical lymphadenectomy may be an oncologically
superior operation with better long-term survival with the downsides of increased operative morbidity
and mortality especially pulmonary complications. Minimally invasive approaches may be a promising
alternative with decreased post-operative complications without compromising the radicality of the
surgery. The current evidence suggests the potential benefits for minimally invasive esophagectomy
approach to GEJ tumours include smaller incisions, less intraoperative blood loss fewer postoperative
complications, shorter admission to the intensive care unit and overall hospital stay, better preservation
of postoperative pulmonary function and equivalent quality of lymph node dissections [46-49] . The evidence
for minimally invasive surgeries for GEJ tumours is convincing, however more prospective studies are
required to evaluate the long-term oncological outcomes.

Multimodality management of GEJ tumours
Multimodality treatment strategies in locally advanced GEJ tumours (T2 and higher or node positive)
result in improved outcomes. These strategies include neoadjuvant and adjuvant chemotherapy with