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limited space. In terms of peri-esophageal lymphadenectomy, transthoracic approach may have superiority
[22]
for en bloc lymphadenectomy .

RECONSTRUCTION METHODS FOR SIEWERT TYPE II AEG
Reconstruction is one of the most difficult steps during the surgery. For early type II AEG, lower esophagectomy
plus proximal gastrectomy seems enough, because of low para-stomach nodal metastasis rate in No. 4, 5
[23]
and 6. While as for advanced type II AEG, lower esophagectomy plus total gastrectomy is essential . There
are many reconstruction methods for proximal gastrectomy, including esophagogastrostomy, gastric tube
[26]
reconstruction [24,25] , double tract , different kinds of jejunal interposition and double flap method [27,28] . The
major concern for proximal gastrectomy is the high incidence of postoperative complications, reflux esophagitis
especially, which is a negative factor for quality of life. Many reconstruction methods are meant to resist reflux,
while it remains lacking consensus. A retrospective study demonstrated that double tract reconstruction is a
[29]
simple and effective method in decreasing reflux esophagitis compared with Roux-en-Y . It still needs RCT to
provide high-grade evidence for the method.

Compared with open surgery, minimally invasive surgery has unique advantages, such as acceptable lymph
[30]
node retrieval, good postoperative outcomes, and low mortality . Many experienced surgeons choose
[31]
minimally invasive surgery for type II AEG . Laparoscopic-assisted proximal gastrectomy is prevalent for
type II AEG. Because circular stapler can finish a higher anastomosis level, it is easier for type II AEG with
R0 resection. And the key procedure of using circular stapler in totally laparoscopic procedure is placing
the anvil to the stump of esophagus. Transorally inserted anvil (OrVil) [31,32] and hemidouble stapling
[33]
technique are two easy methods to accomplish that. Recently, it has become more and more popular
for totally laparoscopic technique. Liner stapler is a good choice for totally laparoscopic anastomosis, such
[34]
as Overlap method . But compared with laparoscopic-assisted gastrectomy, which could provide some
reference for the border of tumor through a sense of touch, it is harder to ensure R0 resection, especially
in advanced type II AEG. In addition, there is little space to use such devices, especially for type II AEG
[35]
which needs a high anastomosis level. Takiguchi et al. introduce laparoscopic mediastinal dissection via
an open left diaphragm approach for advanced type II AEG. Firstly, divide phrenicoesophageal ligament
around the esophagus along the esophageal hiatus. Then, open the left side of mediastinal pleura and
incise the left diaphragm with a 60-mm linear stapler. So that, it creates a clear space and a good view for
the further mediastinal lymph node dissection and reconstruction. Although no severe complication was
seen in this study, it is still unknown whether this method is more harmful compared with transthoracic
approach like Ivor-Lewis. The method may lead to a larger trauma which needs to place an intrathoracic
drainage tube. And a larger sample size was needed to provide more evidence.

The incidence rate of AEG has been on the rise for decades. Siewert classification has become the standard
classification for AEG. Siewert type I AEG should be treated as esophagus cancer, while type III should
be regarded as gastric cancer. Because of the unique location of Siewert type II AEG, the treatment still
doesn’t reach consensus. Surgery remains the fundamental treatment, a lot of detail during surgery are
needed to research in the future.

DECLARATIONS
Authors’ contributions
Concept and design: Zang L
Manuscript preparation: Li SC
Manuscript review: Zang L

Availability of data and materials
Not applicable.