Eric Davies, MD, Rupert Horoupian, MD. Department of Surgery, Alta Bates Summit Medical Center, Oakland, CA
Background: Resection of type II and III gastroesophageal junction tumors can be challenging given their anatomical location. Transabdominal minimally invasive resection with D1 lymphadenectomy have been described, though controversy remains regarding the optimal anastomotic technique. Adjuvant radiation can cause stricturing of an esophagogastric (EG) anastomosis that was created with an EEA stapler. Side-to-side (anterior to posterior) EG anastomosis forms a larger opening. In this video, we demonstrate the technique of a robotic distal esophagectomy and proximal gastrectomy and side-to-side EG anastomosis using an endo-GIA stapler.
Case Report: Our patient was a 71-year-old female with no significant past medical history. She presented to the emergency department with 3 days of epigastric pain associated with progressive nausea and vomiting. A CT scan revealed multiple hepatic cysts, one of which was hemorrhagic. A gastroenterology consult was obtained, and a routine esophagogastroduodenoscopy found an incidental GE junction tumor. Endoscopic ultrasound demonstrated an 11x27mm T3N1 lesion with biopsies positive for adenocarcinoma with local lymph node metastasis. She underwent three cycles of neoadjuvant chemotherapy, and post treatment PET scan indicated excellent response. Six weeks later, we performed an intraoperative liver ultrasound and biopsy followed by a robotic resection of the distal esophagus and proximal stomach with D1 lymphadenectomy. A partial Kocher maneuver and pyloromyotomy was also performed. The remaining stomach was anastomosed to the distal esophagus in a side-to-side fashion using an endo-GIA stapler and the enterotomy was sutured closed. The specimen was removed through a 5cm Pfannenstiel incision.
Summary: There were no intraoperative complications. Blood loss was minimal, and postoperative pain control was excellent. A gastrografin esophagogram on postoperative day eight demonstrated an intact anastomosis without leak. The nasogastric tube was removed, her diet was slowly advanced to full liquids, and she was discharged home. The final pathology report revealed a 26 lymph node harvest with clear proximal and distal margins.