Patients
This retrospective study assessed the clinical outcomes of patients who underwent transhiatal reconstruction after laparoscopic PGLE for Siewert type II tumors in the period from April 2015 to August 2020 at Kobe University. The preoperative diagnosis in all patients was based on endoscopy and computed tomography scans. All tumors included in this study were confirmed as Siewert type II adenocarcinomas by preoperative examination. In all patients, preoperative endoscopic marking was performed by placing two clips on the proximal edge of the tumor 1–7 days prior to surgery. At least one surgeon who was qualified to perform laparoscopic gastrectomy according to the Endoscopic Surgical Skill Qualification System in Japan [16] participated in all the surgeries. Exclusion criteria included patients who had previously undergone synchronous surgeries combined with laparoscopic PGLE and who had a history of upper abdominal surgery. In all patients, lymph node dissection and reconstruction in laparoscopic PGLE were performed using the same established method. The Japanese Classification of Gastric Carcinoma (3rd English edition) was used for TNM staging [17].
The study was approved by the ethics committee of Kobe University (No. B210278). All patients provided written informed consent for permission on the anonymous use of surgery-related data.
Surgical procedures
In all patients, laparoscopic PGLE was performed as follows. Under general anesthesia, the patient was placed in the reverse Trendelenburg position with their legs apart. The first 12-mm trocar was inserted through an umbilical incision via the open surgical method, a 10-mm flexible laparoscope (Olympus Optical, Tokyo, Japan) was inserted through the port, and pneumoperitoneum was established. The second 12-mm trocar was inserted from inside the right costal margin, and a 5-mm trocar was inserted from outside the right costal margin. A 5-mm trocar was inserted 20-mm above and to the left of the umbilicus, and the third 12-mm trocar was inserted from the left costal margin. The fourth 12-mm trocar was inserted from the epigastric region. A constant intraabdominal pressure of 10 mmHg was maintained during the procedure.
Lymph node dissection
After lifting the lateral liver segment [18], the dissection of the following lymph nodes was performed based on tumor location, according to the Japanese Gastric Cancer Treatment Guidelines 2020 (5th edition): tumors within the submucosa, 1, 2, 3a, 7, 9, 19, 20, 110, 111, and 112; tumors deeper than the submucosa, 1, 2, 3a, 7, 8a, 9, 11p, 11d, 19, 20, 110, 111, and 112 [19]. In some patients with advanced cancer, lymph nodes in the area around the left renal vein (16a2lat) were laparoscopically sampled.
The operator and the first assistant stood on the patient’s right and left sides, respectively, and the camera operator stood between the patient’s legs. On the greater curvature, the right gastroepiploic artery was preserved and the left gastroepiploic and short gastric arteries were dissected around the root. On the lesser curvature, the section from the first to the third branch of the right gastric artery was preserved. Before proceeding with mediastinal lymph node dissection, a 40-mm incision was made in the left diagram using a 45-mm stapler device (SigniaTM with a Tri-staple, 45-mm camel cartridge; Medtronic, Ireland, Dublin) and a surgical retractor (Endo Retract IITM, 10 mm; Medtronic, Ireland, Dublin) was inserted via the epigastric port. The epicardium was lifted using a surgical retractor, and mediastinal lymph node dissection was performed.
Reconstruction
The operator and the first assistant stood on the patient’s right and left sides, respectively, and the camera operator stood between the patient’s legs. During reconstruction, the surgical view of the mediastinum was secured by lifting the epicardium using a surgical retractor. In all patients, intraoperative endoscopic examination was performed to confirm the proximal edge of the tumor by locating the marking clips placed preoperatively and to determine the oral cutting line at least 20 mm away from the clips. The lower esophagus was transected from front to back at least 20 mm proximal to the cutting line using an endoscopic linear stapler (SigniaTM with a Tri-staple, 60-mm purple cartridge) from the inside right port of the operator. Next, the entire stomach and regional lymph nodes were removed through a minimally enlarged 40-mm umbilical incision using a retrieval pouch (Endocatch IITM; Medtronic, Ireland, Dublin). After examining the physical characteristics of the lesion, such as tumor depth and location, a gastric tube (40–50 mm in width) was created using a linear stapler (SigniaTM with a Tri-staple, 45-mm or 60-mm purple cartridge) under direct vision and a small opening was created 60-mm distal from the top of the gastric tube (Fig. 1a, b). Next, the gastric tube was reinserted into the abdominal cavity and a small hole was laparoscopically created at the dorsal edge of the esophageal stump. A linear stapler (SigniaTM with a Tri-staple, 45-mm purple cartridge) was then inserted from the assistant’s lower left port, which was parallel to the esophagus and at an angle of 45°–60° with the gastric tube (Fig. 2a), and esophagogastric tube anastomosis was established using a 25–45-mm-long linear stapler by utilizing 45-mm cartridges (Fig. 2b). Of note, full stapling with a 45-mm stapler was routinely performed until July 2017, whereas short stapling, having a length of 25–40 mm, using a 45-mm stapler was routinely performed from December 2017. The esophagogastric tube anastomosis was completed in a y-shaped angle, and a pseudo-His angle was created using the distal esophagus and gastric tube (Fig. 2c). After firing of the linear stapler, the common entry hole was closed using a full-thickness intracorporeal running suture, 25 cm in length, using 3-0 VicrylTM (Ethicon GmbH, Norderstedt, Germany) (Fig. 2d). Additional suturing in the seromuscular layer was completed using a running suture with 3-0 PDSTM, 20 cm in length, and Lapra-TyTM clips (Ethicon GmbH, Norderstedt, Germany) through the entry hole and both sides of the distal esophagus, to be fixed flatly on the anterior gastric tube (Fig. 2e). A nasogastric tube was not routinely placed into the anastomosis and gastric tube. A soft silicone drain was placed around the anastomotic site through the seventh intercostal trocar under laparoscopic observation via the opened left diaphragm (Fig. 2f), which was closed by utilizing an intracorporeal suture using 2-0 Ethibond (Ethicon). Short video clips of the transhiatal y-shaped overlap esophagogastric tube reconstruction during laparoscopic PGLE can be viewed in the Supplementary Video.
Operative complications
Data on operative complications and postoperative clinical course were retrospectively retrieved from the database. Postoperative complications included all major and minor complications and were graded according to the Clavien–Dindo classification [20].
Follow-up protocol
All patients underwent follow-up examination, including regular physical examination and laboratory blood tests, at 3, 6, and 12 months after surgery. The prophylactic proton pump inhibitor (PPI) was recommended at least 12 months after surgery. Postoperative reflux symptoms were evaluated using the modified Visick score at 12 months after surgery [21]. The grade of endoscopic RE was classified and assessed using the Los Angeles classification [22], and the degree of food residue was evaluated according to the residue/gastritis/bile classification [23] based on endoscopy performed at 12 months after surgery.
Statistical analysis
All statistical analyses were performed using JMP software version 8.0 (SAS Institute, Cary, NC, USA). Continuous variables were presented as medians (range) or [interquartile range], and analyses included Fisher’s exact test and the Mann–Whitney U test. A P value of <0.05 was considered to indicate statistical significance.