Quantitative Fluorescent Guided Robotic Surgery for Cancer of the Gastroesophageal Junction

2. Introduction

2.1 Adenocarcinoma of the gastroesophageal tract Adenocarcinoma of the gastroesophageal tract, including the esophagus, stomach, and gastroesophageal junction (GEJ) is a growing clinical challenge worldwide due to the increasing incidence and poor prognosis. Current management of resectable GEJ cancer involves comprehensive diagnostic procedures followed by standardized treatment with surgery and pre- and postoperative chemotherapy.

At our department, 90 patients are annually treated for resectable cancer of the GEJ. The surgery comprises of an Ivor Lewis procedure with either open or robot-assisted mobilization of the stomach with limited (D1+) lymphadenectomy and creation of the gastric conduit and pyloroplasty (2). Here, the creation of the gastric conduit involves partial preservation of the right gastric artery. The right gastric artery is ligated approximately half way up the lesser curvature, and the remaining conduit stapled (figure 1). Theoretically, the preservation of both the gastro-epiploic and right gastric artery should result in improved vascular patency and blood supply to the anastomosis. The theoretical advantages of preserving the right gastric artery may have some oncological drawbacks as placing the line of resection half way up the lesser curvature allows for a limited lymph node (LN) dissection, leaving behind some tissue comprising of LN station number 3b and 5 (figure 1). Lymph node metastasis is a significant prognostic factor in gastroesophageal cancer, and the American Joint Committee on Cancer recommends an extensive lymphadenectomy to achieve accurate N staging.

In contrast, the creation of a gastric tube by serial applications of a linear-cutting stapling device parallel to the greater curvature (ligating the right gastric artery) could generate a larger LN harvest, but this could be at the expense of anastomotic and conduit perfusion. A retrospective series noted an increase in gastric tip necrosis and neck leaks with intrathoracic extension when a narrower gastric tube (3 to 4 cm) was used. Contrary, several randomized trials, and cohort studies have been conducted regarding the size of the gastric tube with no differences in anastomotic leakage rates being reported. However, the consensus is that a gastric tube of five cm width in both open and minimal invasive oesophagostomy is the optimal size. No difference in the rates of anastomotic leakage, anastomotic stenosis, or delayed gastric emptying has been seen between ligating or preserving the right gastric artery. Thus, both ligating and preserving the right gastric artery are considered viable surgical options.

Figure 1. A) Schematic image of the gastric blood vessels. B) Resection when ligating the right gastric artery, C) Resektion when preserving the right gastric artery. D) Schematic image and partial lymphatic overview, circled are lymph node stations 3b. and 5. resected in "B" and left behind in "C".