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Thoracoscopic Esophagojejunostomy in the Upper Mediastinum After Thoracoscopic Esophagectomy with Total Gastrectomy.

BACKGROUND
Esophagectomy and esophageal reconstruction with organs other than the gastric tube are complicated and difficult surgical procedures. We developed a new method of thoracoscopic esophagectomy with intrathoracic esophagojejunostomy in the upper mediastinum when the gastric tube cannot be used as an esophageal substitute for reconstruction.


MATERIALS AND METHODS
Total gastrectomy, preparation of pedicled jejunal conduit, and transhiatal lower mediastinal dissection were done under laparotomy. Upper and middle mediastinal dissection was performed thoracoscopically. After esophageal transection with a linear stapler above the arch of the azygos vein, an anvil was inserted transorally. A circular stapler-inserted jejunal conduit was introduced to the upper mediastinum via the transhiatal route with relaparotomy. Esophagojejunostomy was completed by double stapling technique.


RESULTS
We completed this procedure for 10 consecutive cases without conversion to thoracotomy. The median operation time, amount of blood loss, duration of intrathoracic anastomosis, and number of dissected total and thoracic nodes was 741 (665-1019) minutes, 835 (380-2090) ml, 94.5 (70-211) minutes, and 59 (16-165) and 30 (10-54) nodes, respectively. There was no anastomotic leakage, conduit necrosis, or hospital mortality. Two cases showed delayed anastomotic stenosis. The median body weight loss 3 months after surgery was 13.9%. The overall 5-year survival rate was 90% (stage I, 100% and stage III, 83.3%).


CONCLUSIONS
Thoracoscopic esophagectomy with intrathoracic esophagojejunostomy is safe and curative. This operation can be performed as a minimally invasive surgical procedure for esophageal cancer patients in whom the stomach cannot be used as a reconstruction conduit.