A 68-year-old asymptomatic man was referred to our hospital for evaluation because of an irregularity in the gastric body, which was detected during a medical examination. His blood tests revealed no abnormalities, except for an elevated HbA1c level of 6.9%. Endoscopy and upper gastrointestinal series showed not only a type 0-IIc and 0-III gastric tumor (25 mm) with an ulceration at the posterior wall of the middle third of the stomach (Figure 1a and b) but also a type 0-IIc tumor (right, half-circumferential; 30 mm) in the lower third of the esophagus (Figure 1c,d). The biopsies of the tumors revealed squamous cell carcinoma in the thoracic lower esophagus (cT1bN0M0, cStageIA) and well- and moderately differentiated adenocarcinoma of the stomach (T1bN0M0, cStageIA). A computed tomography (CT) scan showed no primary tumor in the stomach or esophagus, no lymph node metastasis, and no tumors in other organs such as the liver and lungs. Colonoscopy and CT scan were performed to evaluate the colon and the patency of the middle colic vessels. Two polyps were detected in the ascending colon, and endoscopic polypectomy was performed 2 days prior to tumor resection.
The patient chooses TSEP for clinical stage I esophageal cancer among the therapies of TSEP, chemoradiotherapy or proton therapy, and informed consent was obtained.
Tumor surgery
Thoracoscopic esophagectomy in the prone position
TSEP was performed thoracoscopically, as previously described [10], with the patient intubated under epidural and general anesthesia. Five chest trocars were introduced (Figure 2), and carbon dioxide (CO2) was insufflated at a pressure of 8 mmHg to expand the mediastinum, maximizing the exposure of the intrathoracic esophagus without the need for additional retraction of the surrounding structures.
TSEP with mediastinal lymph node dissection involved three steps. First, a dissection of the middle to lower mediastinal lymph nodes was performed. The esophagus was circumferentially mobilized from the descending aorta, pericardium, and the left mediastinal pleura. The vagal trunk was cut below the level of its pulmonary branch, and the thoracic duct was preserved. Second, the procedure transitioned to the upper thorax. The arch of the azygos vein was cut using the linear stapler, and the right recurrent laryngeal nerve was identified just caudal to the right subclavian artery to ensure preservation. The fatty tissue containing lymph nodes around this area was dissected, and the right recurrent laryngeal nerve up to the inferior border of the thyroid gland was preserved. The esophagus was retracted by pulling the taped thread around the upper third of the esophagus, and en bloc dissection of the lymph nodes was performed by using scissors to prevent injury to the left recurrent laryngeal nerve below the aortic arch to the inferior border of the thyroid gland - no electrical or heat-producing devices were used. Finally, after the upper third of the esophagus was mobilized circumferentially, the esophagus was divided at the level of the arch of the azygos vein by linear stapling, and the esophagus was dissected by exposing the left side of the mediastinal pleura by retracting the anal stump. After complete mobilization of the esophagus, the subcarinal and bilateral bronchial lymph nodes were dissected completely. After the thoracoscopic procedures were completed, a chest tube was inserted.
Laparoscopic total gastrectomy
The position of patient was changed to the supine position under general anesthesia without a blocking balloon for double-lung ventilation. After five abdominal trocars were introduced (Figure 3) and CO2 was insufflated at a pressure of 10 mmHg to expand the abdomen, LTG with D1+ lymphadenectomy according to the Japanese Gastric Cancer treatment guidelines 2010 [13] was performed in five steps. First, the left and right greater omentum and lymph nodes were dissected along the gastroepiploic and infrapyloric vessels. Second, the duodenum, just distal to the pyloric ring, was transected by linear stapling. Third, the left lobe of the liver was retracted using a Penrose drain to expose the anatomy around the esophagogastric junction, as reported by Sakaguchi et al. [14]. Fourth, the suprapyloric nodes and nodes along the left gastric artery, common hepatic artery, splenic artery, and celiac artery were dissected. Finally, the abdominal esophagus was exposed after full mobilization of the stomach was achieved.
Laparoscopically assisted colon reconstruction
We added another three trocars, and the right colon was mobilized (Figure 3). After the infraumbilical incision was extended to 40 mm, the esophageal and gastric tumors were removed via mini-laparotomy simultaneously. The terminal ileum was divided into 4 cm proximally to the ileocecal valve by linear stapling, and the ileocolic vessels and accessory colic vein were divided. The blood supply for the right and transverse colon segments was from the middle colic vessels and there was innately no right colic artery and vein. Colonic interposition and Roux-en-Y colo-jejunal reconstruction were performed via the posterior mediastinum (Figure 4). During the abdominal approach, cervical lymph node dissection was performed in parallel.
Five chest trocar incisions, a 4-cm mini-laparotomy in the middle of the abdomen, and another seven abdominal trocar incisions were required. The operation was 545 min long, and blood loss was 95 g. Postoperatively, the patient did not have any major complications. However, there was a paralytic ileus, which was relieved using conservative treatment with an ileus tube. The pathological examination revealed no metastases in 56 harvested lymph nodes and no residual tumor. He was discharged 29 days postoperatively and was followed up for 30 months without any indications of recurrence or distant metastases.
