Current status of high-positioned digestive tract reconstruction after laparoscopic proximal stomach and lower esophagus resection through the abdominal-left diaphragmatic approach for adenocarcinoma of esophagogastric junction

Abstract

In recent years, the rising incidence of adenocarcinoma of esophagogastric junction (AEG) and the subsequent surge in early detections have transformed the surgical treatment of AEG into a topic of substantial interest. The anatomical positioning of AEG, combined with the unique nature of its tumor biology, which encompasses two distinct surgical domains, the thoracic and abdominal cavities, has sparked numerous debates regarding the selection of treatment strategies. The comprehensiveness of lymph node dissection and the safety of digestive tract reconstruction are instrumental in shaping these strategies. The laparoscopic abdominal transhiatal (TH) approach offers a balance of addressing both these conside-rations. It ensures the oncological safety of inferior mediastinal lymph node dissection, while simultaneously performing abdominal lymph node dissection. This approach becomes a prime choice for AEG when the esophageal invasion length is ≤ 4 cm.When implementing the TH approach, surgeons have the ability to either augment the inferior mediastinal space or establish a direct connection between the abdomen and the left thoracic cavity by performing a strategic opening of the left diaphragm. Such a maneuver circumvents the need for traditional thoracotomy, thus enlarging the operating space and enhancing the surgical field of view. This method reduces chest trauma and enables a clearer and more comprehensive removal of inferior mediastinal lymph nodes. Moreover, ample operating space and sufficient esophageal dissection make high digestive tract reconstruction in the mediastinum or left thoracic cavity safer and more feasible. Our center has dubbed this approach the abdominal-left diaphragmatic (ALD) approach. Functional digestive tract reconstructions such as side overlap esophagogastrostomy （SOFY） anastomosis and double-flap technique can be progressively applied to a higher anastomosis plane through the ALD approach. Consequently, the ALD approach expands the indications for digestive tract reconstruction, ensures operational safety, and maintains an effective anti-reflux effect simultaneously.

Keywords

• |gastric cancer|adenocarcinoma of esophagogastric junction|proximal gastrectomy|digestive tract reconstruction|left thoracic cavity