Robert B Yates, MD, Brant K Oelschlager, MD. University of Washington
Background
Operative resection of gastroesophageal junction (GEJ) tumors can be performed via esophagectomy or total gastrectomy. These operations are fraught with significant perioperative morbidity and mortality. In patients with Siewert Type 2 and 3 GEJ tumors and significant medical comorbidities that place them at too high of risk to undergo esophagectomy or total gastrectomy, we perform laparoscopic esophagogastrectomy, a local resection of the distal esophagus, GEJ, and proximal stomach. In this video submission, we present one patient who underwent this operation, emphasizing our operative technique.
Case Study
A 72 year-old man with stage IIa (uT2N0) adenocarcinoma of the GEJ (Siewert Type 3) presented for evaluation. His past medical history included atrial fibrillation, hypertension, sick sinus syndrome, peripheral arterial disease, diabetes, chronic renal insufficiency and obesity (BMI 35). We recommended operative resection by laparoscopic esophagogastrectomy.
Results
The accompanying video demonstrates the operative technique. There were no intraoperative or immediate postoperative complications. On postoperative day 4, an esophagram was obtained, which demonstrated an intact esophagogastric anastomosis and normal gastric emptying. A clear liquid diet was started. The next day, the patient experienced an acute myocardial infarction and underwent left heart catheterization. A 90% stenosis of his left anterior descending artery was identified, and a bare metal stent was placed. He was discharged on postoperative day 8 without further complication. Final pathology demonstrated adenocarcinoma, pT1bN2 (5/35 nodes positive). Closest margin was 1.4 cm (radial). At 2 month follow-up, his only complaint was mild heartburn and regurgitation, which were controlled with proton pump inhibitor therapy.
Discussion
For patients with Siewert Type 2 and 3 GEJ tumors that we deem too ill to undergo esophagectomy or total gastrectomy, we recommend laparoscopic esophagogastrectomy. This totally laparoscopic resection of the distal esophagus and proximal stomach achieves complete removal of the primary tumor and associated lymphatic tissues. Compared to esophagectomy and total gastrectomy, it is a shorter operation and does not require an extensive mediastinal dissection and laparotomy, which are associated with increased postoperative pulmonary and cardiac complications. Although this patient experienced an acute postoperative myocardial infarction, we speculate that the physiologic stress incurred during an esophagectomy or total gastrectomy would have resulted in a worse outcome. The downside of this operation is the near-universal development of postoperative symptoms gastroesophageal reflux. Typically, however, these can be effectively managed with proton pump inhibitor therapy. Laparoscopic esophagogastrectomy is not appropriate for more proximal (Siewert type 1) tumors, because esophageal transection and creation of an esophagogastric anastomosis at this location is not possible laparoscopically.
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