Page 132 - Read Online

Shibao et al. Mini-invasive Surg 2019;3:16 I http://dx.doi.org/10.20517/2574-1225.2019.01 Page 3 of 8

The right transthorathic approach is possible to ensure a sufficient proximal margin even in EGJ cancer with
long esophageal invasion. The upper mediastinal LNs can be removed by this approach. However, because
of the surgical stress associated with thoracotomy, careful management is required to avoid postoperative
pneumonia. There are two types of left transthorathic approaches in open surgery: the left thoracoabdominal
approach, with an oblique incision from the left thorax to the abdomen, and left thoracophrenolaparotomy,
which includes laparotomy and transdiaphragmatic thoracotomy. The one of the merit of these techniques is
no requirement of repositioning during surgery. However, it is not possible to dissect the upper and middle
mediastinal LNs with these approach.

The transhiatal approach, consists of transhiatal surgery on the abdomen and lower mediastinum and does
not require thoracotomy. The procedures in the lower mediastinum include lower esophagectomy and only
peri-esophageal LN dissection. Respiratory damage appears to be less than with the other approaches.
Although en bloc dissection of the lower mediastinal LNs is possible, the surgical view of the mediastinum
of this approach in open surgery is worse compared with the other approaches.

In general, Siewert type I cancer should be treated with en bloc transthoracic or transhiatal resection. The
transthoracic approach is most beneficial, especially in advanced Siewert type I cancer, and the appropriate
extent of lymphadenectomy (two-field Ivor-Lewis esophagectomy or three-field McKeown esophagectomy)
remains a focus of discussion [16,17] . Generally, transhiatal esophagectomy has limitations due to the inability
of mediastinal lymphadenectomy and should therefore be applied for frail patients.

The standard surgical approach for Siewert type II and type III cancers involves total gastrectomy with D2
lymphadenectomy. In Siewert type II, it involves the transhiatal resection of the distal esophagus with lower
mediastinal lymphadenectomy. Splenectomy and pancreatectomy are not essential if the tumor is not located
along the greater curvature and harbors metastasis of the no. 4sb lymph nodes . Furthermore, in Siewert type
[18]
II and III early cancers, recent evidence suggests that proximal gastric resection with D1 + lymphadenectomy
may contribute to avoid postgastrectomy syndrome without a detrimental effect on complete oncologic
clearance .
[19]

Finally, minimally invasive approaches have been developed as a safe and feasible alternative to traditional
open surgery for the treatment of esophageal cancer [20,21] . Efforts have been made by surgeons to establish
all types of minimally invasive surgery (MIS), including minimally invasive Ivor-Lewis, McKeown
esophagectomy, and transhiatal esophagectomy. An en bloc lymphadenectomy method in the upper and
middle mediastinum with a single-port mediastinoscopic cervical approach that was recently developed by
a Japanese surgeon is a hot topic in the treatment of EGJ cancer . In combination with lower mediastinal
[22]
lymph nodes dissection using laparoscopic trans hiatal approach, they perform total mediastinal
lymphadenectomy under pneumomediastinum assistance without thoracotomy. This technique achieves
minimum invasiveness and has curative potential. Further investigation is needed to evaluate its safety and
feasibility.

EVIDENCE FOR VARIOUS SURGICAL STRATEGIES IN THE MINIMALLY INVASIVE APPROACH
FOR CANCER OF THE EGJ
Table 1 summarized the cited results in this manuscript. Schoppmann et al. described a case controlled
[23]
study (n = 31) that demonstrated higher rates of morbidity, transfusion rate, and postoperative respiratory
complications in MIE comparing to OE. Briez et al. evaluated the impact of a hybrid MIE (HMIE,
[24]
laparoscopic gastric mobilization and open thoracotomy, n = 140) to OE (n = 140) on respiratory complications.
They found that the incidence of respiratory complications at 30 days after HMIE was significantly lower
in comparison to OE. Moreover, the in-hospital mortality and overall morbidity rates were significantly