Invited Commentary
1
11. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph node metastasis and surgical management of gastric cancer invad- ing the esophagus. Hepatogastroenterology 1995;42:37– 42. 12. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662–9. 13. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 pa- tients. Ann Surg 2003;238:486 –95. 14. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Kojima M, Tanaka M. Minimally invasive radical esophagectomy for esophageal cancer. Esophagus 2007;4:59 – 65. 15. Shimizu S, Noshiro H, Nagai E, Uchiyama A, Tanaka M. Laparoscopic gastric surgery in a Japanese institution: anal- ysis of the initial 100 procedures. J Am Coll Surg 2003;197: 372– 8. 16. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Tanaka M. Laparoscopically assisted distal gastrectomy with standard radical lymph node dissection for gastric cancer. Surg En- dosc 2005;19:1592– 6. 17. Shinohara T, Kanaya S, Taniguchi K, Fujita T, Yanaga K, Uyama I. Laparoscopic total gastrectomy with D2 lymph node dissection for gastric cancer. Arch Surg 2009;144: 1138 – 42. 18. Taguchi S, Osugi H, Higashino M, et al. Comparison of three-field esophagectomy for esophageal cancer incorpo- rating open or thoracoscopic thoracotomy. Surg Endosc 2003;17:1445–50. 19. Siewert JR, Stein HJ. Carcinoma of the cardia: carcinoma of the gastroesophageal junction-classification, pathology and extent of resection. Dis Esoph 1996;9:173– 82. 20. Noshiro H, Iwasak T, Kobayashi K, et al. Lymphadenectomy along the left recurrent laryngeal nerve by minimally inva- sive esophagectomy in the prone position for thoracic esophageal cancer. Surg Endosc 2010;24:2965–73. 21. Nunobe S, Ohyama S, Sonoo H, et al. Benefit of mediastinal and para-aortic lymph-node dissection for advanced gastric cancer with esophageal invasion. J Surg Oncol 2008;97:392–5. 22. Inaba K, Satoh S, Ishida Y, et al. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg 2010;211:e25–9. 23. Bracale U, Marzano E, Nastro P, et al. Side-to-side esoph- agojejunostomy during totally laparoscopic total gastrec- tomy for malignant disease: a multicenter study. Surg En- dosc 2010;24:2475–9. INVITED COMMENTARY Dr Noshiro and colleagues [1] have very elegantly de- scribed a minimally invasive technique for resecting ade- nocarcinoma of the gastroesophageal junction (GEJ) and performing an intrathoracic Roux-en-Y esophagojejunos- tomy. The key points of their technique are an extended lymphadenectomy, preparation of a long Roux-en-Y limb with transection of one or two jejunal vascular branches, and a beautifully simple intrathoracic side-to-side anasto- mosis. Their technique is undoubtedly a major advance in the minimally invasive resection of GEJ tumors. These surgeons are to be commended for a major technical feat with excellent short-term and midterm outcomes. Impor- tantly, their report also draws attention to an approach forgotten among many North American thoracic surgeons. How could this procedure evolve to become more widely accepted in our surgical community? First, a simplification of the approach could turn it into a more palatable venture. Could this minimally invasive esoph- agectomy be done in most patients in the modified right lateral decubitus position that is the standard position for a left thoracoabdominal incision? I believe the answer is “yes.” The esophagus can be mobilized en bloc with surrounding soft tissue and subcarinal lymph nodes via a left thoracos- copy in the modified right lateral decubitus position. Left- ward rotation of the operating table allows full access to the abdominal wall for laparoscopy or midline laparotomy. The combination of a single position with Dr Noshiro’s elegant anastomotic technique could facilitate the procedure and shorten operative time. In addition, this approach allows the surgeon to visualize the Roux-en-Y limb at all times to avoid axial rotation and redundancy, and to easily convert to a left thoracotomy, laparotomy, or left thoracoabdominal incision if needed. Second, we need to evaluate the role of this operation in cancer of the GEJ. An esophageal reconstruction with intrathoracic esophagojejunostomy is an excellent option if tumor characteristics or other factors preclude the use of a gastric conduit. The esophagojejunal anastomosis can be made anywhere between the level of the inferior pulmonary vein and the carina. The next question is whether this type of esophagectomy and reconstruction is oncologically and functionally comparable to esopha- gogastric reconstruction in patients with a viable gastric conduit. The mean length of the proximal margin of resection (3.7 cm ex situ), and the extent of the lymph- adenectomy (a mean of 56 lymph nodes removed) would suggest that this procedure is oncologically appropriate for many patients with adenocarcinoma of the GEJ. From the functional perspective, it is currently impossible to determine how the postoperative course and quality of life would contrast for patients undergoing an intratho- racic esophagojejunostomy and those with an intratho- racic esophagogastrostomy. In an era of rapid rise of adenocarcinomas of the GEJ, we should reacquaint our- selves with this procedure and consider a critical ap- praisal of our surgical approach to these patients. I congratulate Dr Noshiro and his team for their groundbreaking, minimally invasive technique for esophagogastrectomy. Rafael Andrade, MD Division of Thoracic and Foregut Surgery University of Minnesota 420 Delaware St SE, MMC 207 Minneapolis, MN 55455 e-mail: [email protected] Reference 1. Noshiro H, Miyasaka Y, Akashi M, Iwasaki H, Ikeda O, Uchiyama A. Minimally invasive esophagogastrectomy for esophagogastric junctional cancer. Ann Thorac Surg 2012;93: 214 –20. 220 NOSHIRO ET AL Ann Thorac Surg MINIMALLY INVASIVE ESOPHAGOGASTRECTOMY 2012;93:214 –20 © 2012 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.10.038 GENERAL THORACIC
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Transcript of Invited Commentary
220 NOSHIRO ET AL Ann Thorac SurgMINIMALLY INVASIVE ESOPHAGOGASTRECTOMY 2012;93:214–20
GEN
ERA
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HO
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11. Yonemura Y, Tsugawa K, Fonseca L, et al. Lymph nodemetastasis and surgical management of gastric cancer invad-ing the esophagus. Hepatogastroenterology 1995;42:37–42.
12. Hulscher JB, van Sandick JW, de Boer AG, et al. Extendedtransthoracic resection compared with limited transhiatalresection for adenocarcinoma of the esophagus. N EnglJ Med 2002;347:1662–9.
13. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al.Minimally invasive esophagectomy: outcomes in 222 pa-tients. Ann Surg 2003;238:486–95.
14. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Kojima M,Tanaka M. Minimally invasive radical esophagectomy foresophageal cancer. Esophagus 2007;4:59–65.
15. Shimizu S, Noshiro H, Nagai E, Uchiyama A, Tanaka M.Laparoscopic gastric surgery in a Japanese institution: anal-ysis of the initial 100 procedures. J Am Coll Surg 2003;197:372–8.
16. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Tanaka M.Laparoscopically assisted distal gastrectomy with standardradical lymph node dissection for gastric cancer. Surg En-dosc 2005;19:1592–6.
17. Shinohara T, Kanaya S, Taniguchi K, Fujita T, Yanaga K,Uyama I. Laparoscopic total gastrectomy with D2 lymph
intrathoracic esophagojejunostomy is an excellent option
© 2012 by The Society of Thoracic SurgeonsPublished by Elsevier Inc
node dissection for gastric cancer. Arch Surg 2009;144:1138 – 42.
18. Taguchi S, Osugi H, Higashino M, et al. Comparison ofthree-field esophagectomy for esophageal cancer incorpo-rating open or thoracoscopic thoracotomy. Surg Endosc2003;17:1445–50.
19. Siewert JR, Stein HJ. Carcinoma of the cardia: carcinoma ofthe gastroesophageal junction-classification, pathology andextent of resection. Dis Esoph 1996;9:173–82.
20. Noshiro H, Iwasak T, Kobayashi K, et al. Lymphadenectomyalong the left recurrent laryngeal nerve by minimally inva-sive esophagectomy in the prone position for thoracicesophageal cancer. Surg Endosc 2010;24:2965–73.
21. Nunobe S, Ohyama S, Sonoo H, et al. Benefit of mediastinaland para-aortic lymph-node dissection for advanced gastriccancer with esophageal invasion. J Surg Oncol 2008;97:392–5.
22. Inaba K, Satoh S, Ishida Y, et al. Overlap method: novelintracorporeal esophagojejunostomy after laparoscopic totalgastrectomy. J Am Coll Surg 2010;211:e25–9.
23. Bracale U, Marzano E, Nastro P, et al. Side-to-side esoph-agojejunostomy during totally laparoscopic total gastrec-
tomy for malignant disease: a multicenter study. Surg En-dosc 2010;24:2475–9.INVITED COMMENTARY
Dr Noshiro and colleagues [1] have very elegantly de-scribed a minimally invasive technique for resecting ade-nocarcinoma of the gastroesophageal junction (GEJ) andperforming an intrathoracic Roux-en-Y esophagojejunos-tomy. The key points of their technique are an extendedlymphadenectomy, preparation of a long Roux-en-Y limbwith transection of one or two jejunal vascular branches,and a beautifully simple intrathoracic side-to-side anasto-mosis. Their technique is undoubtedly a major advance inthe minimally invasive resection of GEJ tumors. Thesesurgeons are to be commended for a major technical featwith excellent short-term and midterm outcomes. Impor-tantly, their report also draws attention to an approachforgotten among many North American thoracic surgeons.
How could this procedure evolve to become morewidely accepted in our surgical community?
First, a simplification of the approach could turn it into amore palatable venture. Could this minimally invasive esoph-agectomy be done in most patients in the modified rightlateral decubitus position that is the standard position for a leftthoracoabdominal incision? I believe the answer is “yes.”The esophagus can be mobilized en bloc with surroundingsoft tissue and subcarinal lymph nodes via a left thoracos-copy in the modified right lateral decubitus position. Left-ward rotation of the operating table allows full access to theabdominal wall for laparoscopy or midline laparotomy. Thecombination of a single position with Dr Noshiro’s elegantanastomotic technique could facilitate the procedure andshorten operative time. In addition, this approach allowsthe surgeon to visualize the Roux-en-Y limb at all times toavoid axial rotation and redundancy, and to easily convertto a left thoracotomy, laparotomy, or left thoracoabdominalincision if needed.
Second, we need to evaluate the role of this operationin cancer of the GEJ. An esophageal reconstruction with
if tumor characteristics or other factors preclude the useof a gastric conduit. The esophagojejunal anastomosiscan be made anywhere between the level of the inferiorpulmonary vein and the carina. The next question iswhether this type of esophagectomy and reconstructionis oncologically and functionally comparable to esopha-gogastric reconstruction in patients with a viable gastricconduit. The mean length of the proximal margin ofresection (3.7 cm ex situ), and the extent of the lymph-adenectomy (a mean of 56 lymph nodes removed) wouldsuggest that this procedure is oncologically appropriatefor many patients with adenocarcinoma of the GEJ. Fromthe functional perspective, it is currently impossible todetermine how the postoperative course and quality oflife would contrast for patients undergoing an intratho-racic esophagojejunostomy and those with an intratho-racic esophagogastrostomy. In an era of rapid rise ofadenocarcinomas of the GEJ, we should reacquaint our-selves with this procedure and consider a critical ap-praisal of our surgical approach to these patients.
I congratulate Dr Noshiro and his team for theirgroundbreaking, minimally invasive technique foresophagogastrectomy.
Rafael Andrade, MD
Division of Thoracic and Foregut SurgeryUniversity of Minnesota420 Delaware St SE, MMC 207Minneapolis, MN 55455e-mail: [email protected]
Reference
1. Noshiro H, Miyasaka Y, Akashi M, Iwasaki H, Ikeda O,Uchiyama A. Minimally invasive esophagogastrectomy for
esophagogastric junctional cancer. Ann Thorac Surg 2012;93:214–20.0003-4975/$36.00doi:10.1016/j.athoracsur.2011.10.038
