The technique of fourth jejunal artery-based jejunal conduit for oesophagojejunostomy after thoracolaparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour.

BACKGROUND: Locally advanced long Siewert type II tumor requires total gastrectomy and D2 lymphadenectomy with distal esophagectomy and mediastinal lymphadenectomy for curative resection. In this scenario, a laparoscopic transhiatal approach is not feasible, and the conventional left thoracoabdominal approach is associated with increased morbidity. AIMS AND
OBJECTIVES: To describe a novel technique of fourth jejunal artery based jejunal conduit for thoracoscopic esophagojejunostomy after laparoscopic esophagogastrectomy.
MATERIALS AND METHODS: The laparoscopic total gastrectomy with distal esophagectomy specimen is extracted through the periumbilical incision. A pedicled jejunal conduit based on the fourth jejunal artery is prepared, and the jejunal conduit is placed in the mediastinum under laparoscopic guidance. Using the thoracoscopic approach in a prone position, additional esophageal clearance and subcarinal lymphadenectomy are performed. Handsewn end to side esophagojejunostomy is performed at the level of the carina.
RESULTS: Three patients with long Siewert type II underwent this procedure after neoadjuvant chemotherapy. None of the patients had conduit related complications. All three patients had abdominal lymph node involvement and two patients had mediastinal lymph node involvement.
CONCLUSION: Pedicled jejunal conduit based on the fourth jejunal artery is safe for intrathoracic anastomosis after minimally invasive esophagogastrectomy for locally advanced Siewert type II tumor.

INTRODUCTION

Siewert type 2 gastro-oesophageal junction (GEJ) tumours include tumours with varying involvement of the stomach and oesophagus with their epicentre 1 cm above to 2 cm below the GEJ.[1] As type 2 tumours are defined based on the epicentre of cancer, it includes tumours of varying lengths. In some locally advanced Siewert type II tumours, the proximal oesophageal margin can become positive even after resection of distal 4–5 cm of the oesophagus, requiring further oesophageal resection.[2] In such a scenario, laparoscopic oesophagojejunostomy becomes technically difficult. Furthermore, in these groups of patients, mediastinal lymph node dissection is essential, requiring a thoracic approach.[3] This report describes a novel technique of fourth jejunal artery-based jejunal conduit for thoracoscopic oesophagojejunostomy after laparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour.

PRE-OPERATIVE PREPARATION

Upper gastrointestinal endoscopy with biopsy is the first investigation to confirm the diagnosis. Subsequently, contrast-enhanced computed tomography of the thorax, abdomen and pelvis is done to rule out metastasis. Tumours with epicentre in the GEJ along with long gastric (5 cm or more along the lesser curve) and oesophageal (3 cm or more) involvement were considered for this procedure [Figure 1]. Staging laparoscopy is done to rule out metastasis before the initiation of neoadjuvant therapy.

Figure 1

(a) Schematic representation of long Siewert type II tumour. (b) Axial section of computed tomography of the abdomen showing long gastric involvement. (c) Coronal section of the same patient showing long oesophageal involvement

POSITIONING OF PATIENT AND PORTS

Abdominal approach by laparoscopy

The patient is placed in supine with a split leg position. Pneumoperitoneum is created using the open technique (umbilical pillar technique), and 12 mm infraumbilical trocar is placed (camera port). Two 12-mm ports and two 5-mm ports are placed in the pararectal area and below the costal margin [Figure 2]. The 5-mm epigastric port is used for liver retraction.

Figure 2

(a) Port positions for laparoscopic total gastrectomy with D2 lymphadenectomy. (b) Dissection of station 7 lymph node (arrowhead) along the left gastric artery (arrow). (c) Umbilical tape tied around the lower oesophagus to provide traction during hiatal dissection. (d) Lower oesophagus transected using a laparoscopic linear cutter. (e) Completed D2 lymphadenectomy bed showing clipped right gastric artery (arrow) and left gastric artery (arrowhead). (f) Specimen of total gastrectomy with distal oesophagectomy

Thoracoscopic approach

The patient is placed in the prone position. A 12-mm camera port is placed in the seventh intercostal space along the midaxillary line. The left hand 12-mm working trocar is placed in the ninth intercostal space along the scapular line. The right hand 5-mm working trocar is placed in the fifth intercostal space along the posterior axillary line. A 5-mm assistant port is placed in the fourth intercostal space between the mid- and anterior axillary line (if required).

OPERATIVE STEPS

Total gastrectomy with D2 lymphadenectomy and omentectomy

Complete omentectomy is performed by dissecting close to the transverse colon, and the lesser sac is entered. The left gastroepiploic and short gastric vessels are divided at the origin to complete dissection of lymph node stations 2, 4sb, 4sa, 11d and 10. The dissection is continued on the right to ligate the right gastroepiploic vessels and dissect lymph node stations 4d and 6. Suprapyloric dissection with ligation of right gastric vessels and harvesting of station 5 lymph nodes is done, followed by transection of the first part of the duodenum using a laparoscopic linear cutter. Dissection is continued along the hepatic artery to reach the left gastric vessels, which are ligated close to their origin. D2 lymphadenectomy is completed by harvesting stations 12a, 8a, 7, 9, 11p and 1 lymph nodes [Figure 2].

Oesophageal transection and retrieval of specimen

The oesophagogastric junction is dissected circumferentially, and an umbilical tape is tied to provide traction and facilitate dissection into the mediastinum for a length of 4–5 cm [Figure 2]. The oesophagus is transected with a laparoscopic linear cutter. Care should be taken to transect the oesophagus above the visible upper margin of the tumour. The total gastrectomy with a distal oesophagectomy specimen is retrieved through a small periumbilical incision using a wound protector.

Pedicled jejunal conduit preparation

The jejunum is transected distal to the first jejunal artery using an open linear cutter. The vascular anatomy of the jejunal mesentery is assessed using the transillumination technique [Figure 3]. The adequacy of vascular supply to the proposed jejunal conduit is assessed after applying bulldog clamps on the second and third jejunal arteries. After confirming the vascular adequacy from the fourth jejunal artery, second and third jejunal arteries are divided at the base to preserve the vascular arcade and create a long pedicled jejunal conduit. Jejunojejunostomy was performed with a laparoscopic linear cutter, and the enterotomy is closed with 3-0 polydioxanone suture. Feeding jejunostomy is fashioned 15 cm distal to jejunojejunostomy. The abdomen is closed, and pneumoperitoneum is re-established.

Figure 3

(a) Assessment of vascular arcade using transillumination with bulldog clips applied over the second and third jejunal arteries to check adequate vascular flow based on the fourth jejunal artery. (b) Fourth jejunal artery-based long jejunal conduit. (c) Jejunal conduit is taken through the retrocolic route without a mesenteric twist. (d) Jejunal conduit placed in the mediastinum

Jejunal conduit placed in the posterior mediastinum

The jejunal conduit is taken through a retrocolic route and placed in the mediastinum. Care should be taken to maintain the orientation of the mesentery and place a long segment (at least 5 cm) of the jejunum in the mediastinum to prevent it from retracting into the abdomen while changing the patient position [Figure 3]. Furthermore, a long suture is tied to the stapled end of the jejunum that can be used to pull the jejunum in the thorax during the thoracoscopic phase. After the closure of the abdominal ports, the patient is placed in the prone position.

Thoracoscopic distal oesophagectomy and lymphadenectomy

The oesophagus is dissected posteriorly from the aorta and anteriorly from the pericardium along with para-oesophageal lymph nodes (stations 108 and 110) till the level of the azygous arch [Figure 4]. Subcarinal lymphadenectomy (stations 107 and 109) is performed, and the oesophagus is divided using cautery to provide an additional 4–5 cm of proximal margin.

Figure 4

(a) Port positions for thoracoscopic distal oesophagectomy with subcarinal lymphadenectomy. (b) Subcarinal lymph nodes dissected (arrow) (c) Post-subcarinal lymphadenectomy (arrow) and oesophageal mobilisation to the level of the azygous vein. (d) Oesophagus transected below the level of the azygous vein. (e) Ryles' tube placed in the jejunum after completion of the posterior layer of oesophagojejunostomy. (f) Completed oesophagojejunostomy at the level of the azygous vein (arrow)

Oesophagojejunostomy

The jejunal conduit is brought close to the oesophagus without any twist. An enterotomy of the size corresponding to the oesophageal opening is made on the segment of the jejunal conduit that reaches the proximal oesophageal end without tension. Single-layer, continuous end-to-side oesophagojejunostomy is fashioned with 3-0 polydioxanone suture [Figure 4]. After completion of the posterior layer of anastomosis, a 16 Fr nasogastric tube is passed into the efferent limb of the jejunum for a length of approximately 15 cm. The anterior layer is then completed. The specimen is delivered through a 12-mm port. A 28 Fr intercostal drainage (ICD) tube is placed through the camera port, and other ports are closed.

POST-OPERATIVE CARE

On the 1st post-operative day, enteral feeds are given through feeding jejunostomy. Oral feeds are started on the 7th post-operative day after a normal oral contrast study. ICD is removed after the resumption of an oral diet. Patients are discharged on the 9th or 10th post-operative day after ensuring tolerance to oral semi-solid feeds. The clinical details and the perioperative outcome of three patients who underwent this procedure are summarised in Table 1.

Table 1

Clinicopathological features of patients who underwent oesophagogastrectomy with intrathoracic oesophagojejunostomy for locally advanced Siewert type II tumour

Patient number	Age	Gender	Neoadjuvant chemotherapy regimen	Post-operative complications (Clavien–Dindo Grade II or more)	Pathological stage (ypTNM)*	Involved lymph node stations**
1	48	Male	CAPEOX#	Pneumonia	T3N2	110, 7
2	43	Female	FLOT##	Nil	T3N1	107, 3
3	58	Male	CAPEOX	Atrial fibrillation	T3N2	4d, 6, 9

#CAPEOX: Capecitabine + Oxaliplatin, ##FLOT: 5 fluorouracil + leucovorin + oxaliplatin + docetaxel, *AJCC Cancer Staging Manual (8th edition), **Lymph node stations as per the Japanese Classification of Oesophageal and Gastric Cancer

DISCUSSION

Management of locally advanced Siewert type II tumours is controversial. In the West, most of the type II tumours are managed with oesophagectomy, whereas extended gastrectomy is preferred in the eastern countries.[4] As most of the studies on type II tumours are retrospective, the predetermined surgical procedure precluded the complete assessment of the lymph node spread. A multicentric Japanese study reported that mediastinal lymph node involvement is common in patients with more than 3-cm oesophageal involvement.[5] Furthermore, when gastric involvement is more than 5 cm, total gastrectomy is required to perform adequate lymphadenectomy. Hence, in patients with long Siewert type II tumour (>5 cm gastric involvement and > 3 cm oesophageal involvement), total gastrectomy with D2 lymphadenectomy and subtotal oesophagectomy with infracarinal lymphadenectomy will be required for curative resection. In the absence of gastric conduit, jejunum and colon are the available options for oesophageal replacement. Advantages of jejunal conduit are reliable blood supply, which is enhanced with the supercharged technique, availability of the significant length of redundant jejunum that can be spared without adversely affecting absorption and rarity of intrinsic pathology in the jejunum.[6] Furthermore, jejunum has intrinsic peristalsis, which improves the quality of life. The primary disadvantage of the supercharged jejunal conduit is the need for a microvascular anastomosis, which increases the technical complexity and complications associated with the procedure.[6] The present technique does not require supercharging and can be safely used for anastomosis until the level of the azygous arch. Furthermore, it allows for adequate lower mediastinal lymph node dissection and provides enough tumour-free proximal margin without added morbidity of the conventional left thoracoabdominal approach.

CONCLUSION

Pedicled jejunal conduit based on the fourth jejunal artery without augmentation is safe for intrathoracic anastomosis after minimally invasive oesophagogastrectomy for locally advanced Siewert type II tumour.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.