Transhiatal laparoscopic esophagectomy with extended lymphadenectomy guided by green-indocyanine imaging for adenocarcinoma of the esophagogastric junction.

INTRODUCTION

Surgical treatment for adenocarcinoma of the esophagogastric junction (AEGJ) has been long-established, from resection margins to the extension of lymphadenectomy [1,2,4]. The addition of cyanine dye, namely indocyanine green (ICG), to identify suspicious lymph nodes (LN) and evaluate organ vascularization may improve results and outcomes [3].

VIDEO

A 58-year-old female patient with Siewert type II AEGJ was administered mFLOX neoadjuvant treatment. After three cycles, she underwent surgical treatment. The day before surgery, an upper endoscopy was performed to inject 0.2 ml ICG 0.5 cm from the proximal and distal tumor margins. The patient underwent laparoscopic transhiatal esophagectomy with extended lymphadenectomy due to a 4 cm distal esophagus compromised margin. We describe the primary steps of the procedure and demonstrate the role of the ICG in the lymphadenectomy.

RESULTS

Surgery was carried out laparoscopically with a cervical approach (McKeown access), and posterior mediastinal gastric tube reconstruction and cervical gastroplasty were performed. During the standard lymphadenectomy, we observed an ICG-positive LN in station 10, which was found positive in the subsequent pathology examination. After these findings, we performed an extended lymphadenectomy through the splenic hilum. The final pathologic assessment was T3N2 (two perigastric and one positive LN at station 10 among 60 retrieved LN). The operative time was 360 min. The patient started a liquid diet on the seventh postoperative day, and she was discharged on the tenth postoperative day.

CONCLUSIONS

ICG may be helpful to guide both extended lymphadenectomy and distal margin evaluation in transhiatal laparoscopic esophagectomy.