Open left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma

Open left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Open left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma Shingo Kanaji, Naoki Urakawa, Hitoshi Harada, Atsushi Shimada, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4267983/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Despite being oncologically acceptable for esophagogastric junction adenocarcinoma with an esophageal invasion length of 3–4 cm, the transhiatal approach has not yet become a standard method given the difficulty of reconstruction in a narrow space and the risk of severe anastomotic leakage. This study aimed to clarify the safety and feasibility of the open left diaphragm method during the transhiatal approach for esophagogastric junction adenocarcinoma. Methods This retrospective study compared the clinical outcomes of patients who underwent proximal or total gastrectomy with lower esophagectomy for Siewert type II/III adenocarcinomas with esophageal invasion via the laparoscopic transhiatal approach with or without the open left diaphragm method from April 2013 to December 2021. Results Overall, 42 and 13 patients did and did not undergo surgery with the open left diaphragm method, respectively. The median operative time was only slightly shorter in the open left diaphragm group than in the non-open left diaphragm group (369 vs. 482 min; P = 0.07). Grade ≥ II postoperative respiratory complications were significantly less common in the open left diaphragm group than in the non-open left diaphragm group (17% vs. 46%, P = 0.03). Neither group had grade ≥ IV anastomotic leakage, and two cases of anastomotic leakage requiring reoperation were drained using the left diaphragmatic release technique. Conclusions Transhiatal lower esophagectomy with gastrectomy using the open left diaphragm method is minimally invasive and safe, highlighting its advantages for Siewert type II/III esophagogastric junction adenocarcinoma with an esophageal invasion length of ≤ 4 cm. adenocarcinoma esophagogastric junction laparoscopy transhiatal reconstruction lower esophagectomy Siewert type II/III adenocarcinoma open left diaphragm method esophagectomy Figures Figure 1 Figure 2 Figure 3 Introduction Incidence rates of esophagogastric junction adenocarcinoma have been increasing globally, including in Japan [ 1 ]. In this regard, proximal gastrectomy (PG) with lower esophagectomy (PGLE) and lymph node dissection has been considered an oncologically adequate treatment approach for Siewert type II adenocarcinoma with an esophageal invasion length of 2.1–4.0 cm [ 2 ], and the proximal margin is recommended to be > 2.0 cm [ 3 ]. Regarding open surgery, one study showed that left-open thoracotomy is not recommended for gastric cancers with an esophageal invasion length of < 3 cm due to the increased risk of developing respiratory complications compared to the transhiatal approach [ 4 ]. However, limited evidence is available on the length of esophageal invasion of gastric cancer that can be safely handled via the laparoscopic transhiatal approach. Furthermore, whether the thoracoscopic, laparoscopic, or combined approach is less invasive in laparoscopic surgery for PGLE or total gastrectomy (TG) with lower esophagectomy (TGLE) remains debatable. A Japanese prospective nationwide multicenter study comparing the postoperative complications of the transthoracic and transhiatal approaches for esophagogastric junction adenocarcinoma found that both approaches showed high rates of anastomotic leakage (12.5% vs. 12.0%, respectively) [ 5 ]. However, cases of grade IV severe anastomotic leakage were observed only in the transhiatal group and not in the transthoracic group (2.7% vs. 0%) [ 5 ]. Furthermore, the aforementioned study found that these approaches were associated with extremely high anastomotic leakage rates (4/21, 19.0%) despite the small number of patients who underwent transhiatal gastrectomy with minimally invasive surgery [ 5 ]. The transhiatal approach with minimally invasive surgery is exceedingly difficult given that it requires a high degree of proficiency in suturing within a confined space, which may lead to high incidence rates of anastomotic leakage. Moreover, drainage may be difficult once an anastomotic leakage occurs, which may result in severe complications. Considering the technical difficulties and risks for complications associated with reconstruction via the transhiatal approach, the Ivor Lewis or McKeown procedures for esophagectomy may be considered in patients with esophagogastric tumors. However, considering the low oncological need for a transthoracic approach for Siewert type II tumors with an esophageal invasion length of ≤ 4.0 cm, these procedures would be excessively invasive compared to laparoscopic PGLE. Takiguchi et al. had been the first to report on a six-case series that used the laparoscopic approach via an opening in the left diaphragm, which provided a good surgical space and a clear view for mediastinal lymph node dissection and reconstruction in patients with Siewert type II adenocarcinoma [ 6 ]. Similarly in 2014, we also introduced the open left diaphragm method for Siewert type II or type III adenocarcinomas with an esophageal invasion length of ≤ 4.0 cm, depending on the cases. However, although our approach provides a clear view of the inferior mediastinum, making large horizontal incisions in the diaphragm can be challenging given its potential to decrease thoracic movement due to paralysis of the diaphragmatic nerve, resulting in increased respiratory complications. Hence, herein, we aimed to evaluate the feasibility and safety of the laparoscopic transhiatal approach with the open left diaphragm method using a stapler device during PGLE or TGLE for Siewert type II/III adenocarcinomas with esophageal invasion. Materials and methods Patients This retrospective study assessed the clinical outcomes of patients who underwent laparoscopic transhiatal PGLE or TGLE with or without the open left diaphragm method for Siewert type II/III adenocarcinomas with esophageal invasion from April 2013 to December 2021 at Kobe University. In 2014, we introduced the open left diaphragm method, which was initially performed at the discretion of the surgeon in cases with high anastomotic difficulty. Since 2018, we have used this method for all laparoscopic transhiatal approaches. All patients were preoperatively diagnosed based on endoscopy and computed tomography scans. All tumors examined in this study were confirmed to be adenocarcinomas of Siewert type II/III with an esophageal invasion length of ≤ 4.0 cm via preoperative examination. Throughout this consecutive period, no subtotal esophagectomy via the Ivor Lewis or McKeown procedure was performed for esophagogastric junction adenocarcinomas with an esophageal invasion length of < 4 cm. For Siewert type II/III adenocarcinomas with an esophageal invasion length of 4 cm of extension toward the stomach. In all patients, preoperative endoscopic marking was performed by placing two clips on the proximal edge of the tumor 1–7 days before surgery. At least one surgeon qualified to perform laparoscopic gastrectomy according to the Endoscopic Surgical Skill Qualification System in Japan [ 7 ] participated in all of the surgeries. In all patients, lymph node dissection and reconstruction during laparoscopic PGLE or TGLE were performed using the same established method. The Japanese Classification of Gastric Carcinoma (3rd English edition) was used for TNM staging [ 8 ]. This study was approved by the ethics committee of Kobe University (No. B210278). All patients provided written informed consent to publish anonymized surgery-related data. Surgical procedures All patients underwent laparoscopic PGLE or TGLE as follows. Under general anesthesia, the patient was placed in the reverse Trendelenburg position with the legs apart. The surgeon and the first assistant stood on the patient’s right and left sides, respectively, while the camera operator stood between the patient’s legs. The first 12-mm trocar was inserted through an umbilical incision via the open surgical method, a 10-mm flexible laparoscope (Olympus Optical, Tokyo, Japan) was inserted through the port, and pneumoperitoneum was established. The second 12-mm trocar was inserted from inside the right costal margin, after which a 5-mm trocar was inserted from outside the right costal margin. Another 5-mm trocar was inserted 20 mm above and left of the umbilicus, and the third 12-mm trocar was inserted from the left costal margin. The fourth 12-mm trocar was inserted from the epigastric region. A constant intra-abdominal pressure of 10 mmHg was maintained during the procedure. According to the Japanese Gastric Cancer Treatment Guidelines 2020 (5th edition), lymph node dissection was performed based on tumor location. Regarding the lower mediastinal lymph node, the following lymph nodes were dissected transhiatally: tumors within the submucosa, 110, 111, and 112; tumors deeper than the submucosa, 110, 111, and 112 [ 9 ]. Laparoscopic transhiatal procedure The following technique was used for the open left diaphragm method (Fig. 1 , Supplementary Video 1). First, the left diaphragmatic leg was separated before performing mediastinal lymph node dissection. Second, an incision was made in the left diaphragm using a 45-mm stapler device (Signia™ with a Tri-staple, 45-mm camel cartridge; Medtronic, Dublin, Ireland) (Fig. 2 a). During mediastinal lymph node dissection and reconstruction, the surgical view of the mediastinum was secured by lifting the separated diaphragm or pericardial sac using the surgical retractor (Endo Retract™ II 10 mm instrument; Medtronic, Dublin, Ireland) via the additional epigastric port or thread and internal organ retractor (B. Braun, Tokyo, Japan) (Fig. 2 b, c). In patients who did not undergo surgery via the open left diaphragm method, the diaphragm was incised longitudinally, the bilateral diaphragmatic legs were separated, and, as a rule, the thoracic cavity was not opened. In all patients, an intraoperative endoscopic examination was performed to confirm the proximal edge of the tumor by locating the marking clips placed preoperatively and determining the oral cutting line at least 20 mm away from the clips. The lower esophagus was transected from front to back at least 30 mm proximal to the cutting line using an endoscopic linear stapler (Signia™ with a Tri-staple, 60-mm purple cartridge) from the inside right port of the surgeon. Reconstruction after PGLE or TGLE was performed following a previously reported procedure [ 10 , 11 ]. A soft silicone drain was usually placed into the left thoracic cavity between the eighth and ninth or seventh and eighth ribs under laparoscopic observation (Fig. 2 d). Thereafter, a towel was folded over the dorsal aspect of the left thoracic cavity to place the drain slightly dorsal to the thoracic cavity, over the diaphragm, and behind the anastomosis (Fig. 2 e). Finally, the opened left diaphragm was closed by intracorporeal suturing using 2 − 0 Ethibond (Ethicon) (Fig. 2 f). Surgical complications Data on surgical complications and postoperative clinical courses were retrospectively retrieved from the database. All postoperative complications (major and minor) were graded according to the Clavien–Dindo classification [ 12 ]. Follow-up protocol All patients underwent follow-up examinations, including regular physical and laboratory blood tests, 3, 6, and 12 months after surgery. Postoperative respiratory complications in the late phase were evaluated through computed tomography performed 6 and 12 months after surgery. Statistical analysis All statistical analyses were performed using JMP software version 8.0 (SAS Institute, Cary, NC, USA). Continuous variables were presented as medians (ranges), and analyses were conducted using Fisher’s exact and Mann–Whitney U tests. A P -value of < 0.05 was considered indicative of statistical significance. Results A total of 55 patients underwent surgery via the laparoscopic transhiatal approach (Table 1 ), among whom 42 and 13 did and did not undergo surgery via the open left diaphragm method, respectively. No significant difference in patient background was observed between patients who did and did not undergo surgery via the open left diaphragm method; however, those in the open left diaphragm group tended to have slightly longer median length of clinical esophageal invasion and esophagectomy than those in the non-open left diaphragm group. Approximately 75% of the patients in the open left diaphragm group and non-open left diaphragm group underwent PG (74% and 77%), whereas approximately 25% underwent TG (26% and 24%). One patient had a history of open surgery (i.e., abdominoperineal resection), whereas another patient simultaneously underwent laparoscopic rectal resection, both of whom were included in the open left diaphragm group. Table 1 Characteristics of patients with esophagogastric junction adenocarcinoma who underwent gastrectomy with lower esophagectomy Variables Open left diaphragm method P- value Yes (n = 42) No (n = 13) Age, years 72 (47–95) 73 (52–84) 0.57 Sex, male/female 34 (81%)/8 (19%) 11 (85%)/2 (15%) 0.76 BMI, kg/m 2 23.4 (16.4–31.1) 21.4 (16.6–31.8) 0.29 ECOG-PS, 0–1/2–3 35 (83%)/7 (17%) 12(92%) / 1(8%) 0.42 ASA-PS, 1–2/3–4 32 (76%)/10 (24%) 9 (69%)/4 (31%) 0.61 CCI, 0/1–3 22 (52%)/20 (48%) 8 (62%)/5 (38%) 0.56 Clinical tumor depth † , T1/T2–4 17 (40%)/25 (60%) 6 (46%)/7 (54%) 0.72 Clinical stage † , I–II/III–IV 31 (74%)/11 (26%) 11 (85%)/2 (15%) 0.42 Neoadjuvant chemotherapy, Yes/No 15 (36%)/27 (64%) 4 (31%)/9 (69%) 0.74 Pathological tumor depth † , T1/T2–4 21 (50%)/21 (50%) 8 (62%)/5 (38%) 0.46 Pathological stage a , I–II/III–IV 24 (57%)/18 (43%) 8 (62%)/5 (38%) 0.78 Type of procedure: PG/TG 31 (74%)/11 (26%) 10 (77%)/3 (23%) 0.82 Length of the clinical esophageal invasion, mm 20 (10–50) 20 (5–40) 0.08 Length of the resected esophagus, mm 40 (30–80) 30 (20–80) 0.09 a Classified by TNM classification 7th edition (International Union Against Cancer). Continuous variables are presented as median and range. Abbreviations: BMI, body mass index; ECOG-PS, Eastern Cooperative Oncology Group performance status; ASA-PS, American Society of Anesthesiologists physical status; PG, proximal gastrectomy; TG, total gastrectomy The surgical outcomes of the patients are summarized in Table 2 . Notably, the median operative time was slightly shorter (although not significantly) in the open left diaphragm group than in the non-open left diaphragm group (369 vs. 482 min; P = 0.07). Moreover, intraoperative left thoracic drain placement was more common in the open left diaphragm group than in the non-open left diaphragm group (88 vs. 31%; P < 0.0001), whereas grade ≥ II postoperative respiratory complications were significantly more common in the latter than in the former (17% vs. 46%; P = 0.03). Most respiratory complications in both groups were either pleural effusion or atelectasis. Grade ≥ II anastomotic leakage was observed in two patients each in the open and non-open left diaphragm groups. One case each in the open and non-open left diaphragm groups required reoperation (Fig. 3 , Supplementary Video 2), both of whom underwent surgery via the laparoscopic approach. Another case in the open left diaphragm group required reoperation for left diaphragmatic hernia and postoperative bowel obstruction. Although no difference in the length of hospital stay was observed between the two groups, patients in the non-open left diaphragm group who received conservative treatment for suture insufficiency had the longest postoperative stay (i.e., 112 days). None of the patients in both groups died or experienced severe grade IV complications, including those requiring postoperative respiratory support or tracheotomy. No differences in the observation period and Eastern Cooperative Oncology Group performance status (ECOG-PS) 12 months after surgery were observed between the open and non-open left diaphragm groups (ECOG-PS: 0.07 ± 0.07 vs. 0.31 ± 0.63; P = 0.14). None of the patients in both groups showed any late complications within 12 months after surgery, including postoperative diaphragmatic herniation and diaphragmatic elevation. Table 2 Surgical outcomes of patients with esophagogastric junction adenocarcinoma who underwent gastrectomy with lower esophagectomy Variables Open left diaphragm method P- value Yes (n = 42) No (n = 13) Operative time, min 369 (244–680) 482 (255–565) 0.07 Estimated blood loss, mL 20 (0–500) 40 (0–370) 0.33 Transfusion, Yes/No 1 (2%)/41 (98%) 1 (8%)/12 (92%) 0.37 Placement of a thoracic drain, Yes/No 37 (88%)/5 (12%) 4(31%) / 9(69%) < 0.0001 Conversion to laparotomy or thoracotomy, n 0 0 1.00 Postoperative complications a 12 (29%) 5 (38%) 0.51 Anastomotic leakage a 2 (5%) 2 (15%) 0.23 Respiratory complications a 7 (17%) 6 (46%) 0.03 Postoperative severe complication b 4 (10%) 1(8%) 0.84 Anastomotic leakage b 2 (5%) 1 (8%) 0.68 Diaphragmatic hernia b 1 (2%) 0 0.57 Small bowel obstruction b 1 (2%) 0 0.57 Respiratory use after surgery, n 0 0 1.00 Tracheotomy or tube tracheotomy, n 0 0 1.00 Mortality, n 0 0 1.00 Length of hospital stay, days 18 (7–78) 20 (12–112) 0.58 Pre- and postoperative changes in ECOG-PS score 0.07 ± 0.07 0.31 ± 0.63 0.14 Observation period, months 37 (6–80) 41 (7–115) 0.38 a Grade II or IIIa according to the Clavien–Dindo Classification b Grade IIIb according to the Clavien–Dindo Classification Abbreviations: ECOG-PS, Eastern Cooperative Oncology Group performance status Discussion This study assessed the feasibility and safety of the laparoscopic transhiatal approach through the open left diaphragm method using a stapler device during PGLE or TGLE for Siewert type II/III adenocarcinomas with esophageal invasion. Notably, the open left diaphragm group showed no severe grade IV or V postoperative complications while exhibiting lower incidence rates of respiratory complications than the non-open left diaphragm group. Moreover, the open left diaphragm group showed a shorter (although not significantly) operative time and lower incidence rates of anastomotic leakage than the non-open left diaphragm group. The open left diaphragm method expanded the operative field in the mediastinum, encompassing the left thoracic cavity. This spacious area facilitated easy and safe reconstruction, although continuous and careful monitoring of blood gases is essential owing to lung deflation caused by pneumoperitoneum. However, we observed that maintaining a pneumoperitoneum pressure of 10 mmHg did not interfere with positive ventilation or blood gas levels in all cases reported herein. An esophageal invasion length of < 4 cm in length has been associated with low frequencies of lymph node involvement in the upper and middle mediastinum, rendering transhiatal reconstruction oncologically sufficient [ 2 ]. However, anastomotic risks associated with the narrow space encountered during transhiatal reconstruction have been one of the primary reasons why some institutes initially select the thoracoscopic approach for reconstruction in cases with Siewert type II/III tumors with esophageal invasion. Although a longitudinal incision through the esophageal hiatus widens the surgical view in the lower mediastinum, a large horizontal incision through the left diaphragm provides an even larger field of view than a longitudinal incision through the esophageal hiatus, as the pericardial sac is no longer an obstacle. This enables reconstruction in a surgical field where the left thoracic cavity appears to be continuous with the abdominal cavity. However, several concerns exist regarding creating a sizable horizontal incision through the left diaphragm. The first concern involves the possibility of increased rates of postoperative diaphragmatic hernias. Incomplete diaphragmatic closures have resulted in one case (2%) of diaphragmatic hernia. Estimates have shown that approximately 10% of patients who undergo minimally invasive esophagectomies develop postoperative diaphragmatic hernias [ 13 ]. The hiatus must be closed properly to prevent diaphragmatic hernias; unfortunately, this can be quite challenging to accomplish laparoscopically given that the diaphragm can be easily torn during repair using a thread. To overcome this problem, continuous suturing along with a staple line had been introduced. The suture line made by the stapling device can also function as a guideline, similar to a fastener. Another concern is that a large horizontal diaphragmatic incision would increase respiratory complications, most of which, however, include atelectasis and pleural effusion. Nonetheless, these complications were observed only in the initial period when no thoracic drain was placed intraoperatively and were no longer observed after the left thoracic drain was placed laparoscopically. Furthermore, no evidence of diaphragmatic elevation would raise suspicion of diaphragmatic nerve palsy, including computed tomography images taken 3, 6, and 12 months after surgery. Although detailed respiratory function tests were not performed, opening the diaphragm did not result in a deterioration of ECOG-PS or only showed a negligible decrease, if any. Opening the left thoracic cavity increased the risk of developing left pyothorax or other problems in the event of an anastomotic leakage. However, our findings showed that the incidence rates of anastomotic leakage were lower in the open left diaphragm group than in the non-open left diaphragm group. Nonetheless, this result can be attributed to the good field of view during reconstruction and adequate confirmation of the entire anastomotic site before surgery. However, given that severe anastomotic leakage can occur with the transhiatal approach [ 5 ], knowledge on how to recover from it to prevent severe pyothorax is also essential. In some cases of left pyothorax, the patient’s vital signs would be unstable, as demonstrated by hypotension and respiratory failure due to septic shock. In such cases, thoracoscopic drainage using a thoracoscope in the left lateral or prone position is expected to be complicated. In cases of anastomotic leakage after opening the left diaphragm, the left thoracic cavity can be easily approached by removing the suture threads that close the diaphragm (Fig. 3 d). In both patients that underwent reoperation, additional sutures at the leak and drainage sites of the left thoracic cavity were possible. We have not yet experienced a case in which anastomotic leakage developed in the abdominal cavity due to suture closure of the diaphragm after reoperation. This study has some limitations. First, this was a single-center study with a small cohort. However, the short- and mid-term surgical outcomes of our novel technique were meaningful considering the rarity of Siewert type II/III adenocarcinomas with esophageal invasion. Second, we did not compare the outcomes between our technique and other approaches, such as the transhiatal approach without diaphragmatic incision and the thoracoscopic approach in a large cohort. Third, in the early phase, the open left diaphragm method was applied only to cases with high anastomotic difficulty, suggesting a potential historical bias. Further studies are warranted to investigate which approach is least invasive for patients undergoing lower esophagectomy for Siewert type II/III tumors with esophageal invasion. Conclusion This study showed that transhiatal lower esophagectomy with gastrectomy via the open left diaphragm method is a minimally invasive and safe approach that can be employed for Siewert type II/III esophagogastric junction adenocarcinomas with an esophageal invasion length of ≤ 4 cm. Declarations Funding : No funding was received for conducting this study. Conflict of interest: We certify that there is no actual or potential conflict of interest in relation to this article. All authors have no conflict of interest. Human rights statement and informed consent: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for participating in the study. Author contributions: SK conceptualized and designed the study, participated in the sequence alignment, and drafted the manuscript. RS, YK, and AS were involved in the acquisition of data. HG, HH, KY, and TO contributed to the analysis and interpretation of data. TK, NU, HH, and TM participated in critical revision of the manuscript. YK conceived the study, participated in its design and coordination, and helped draft the manuscript. All authors have read and approved the final manuscript. References Yamashita H, Seto Y, Sano T, et al. Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma. Gastric Cancer. 2017;20:69–83. Kurokawa Y, Takeuchi H, Doki Y, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study. Ann Surg. 2021;274:120–7. Mine S, Sano T, Hiki N, et al. Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction. Br J Surg. 2013;100:1050–4. Sasako M, Sano T, Yamamoto S, et al. Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial. Lancet Oncol. 2006;7:644–51. Mine S, Kurokawa Y, Takeuchi H, et al. Postoperative complications after a transthoracic esophagectomy or a transhiatal gastrectomy in patients with esophagogastric junctional cancers: a prospective nationwide multicenter study. Gastric Cancer. 2022;25:430–7. Takiguchi S, Miyazaki Y, Shinno N, et al. Laparoscopic mediastinal dissection via an open left diaphragm approach for advanced Siewert type II adenocarcinoma. Surg Today. 2016;46:129–34. Tanigawa N, Lee SW, Kimura T, et al. The endoscopic surgical skill qualification system for gastric surgery in Japan. Asian J Endosc Surg. 2011;4:112–5. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma. 3rd ed. Gastric Cancer. 2011;14:101–12. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018. 5th ed. Gastric Cancer. 2020;24:1–21. Kanaji S, Suzuki S, Harada H, et al. Comparison of two- and three-dimensional display for performance of laparoscopic total gastrectomy for gastric cancer. Langenbecks Arch Surg. 2017;402:493–500. Kanaji S, Suzuki S, Yamamoto M, et al. Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction. Langenbecks Arch Surg. 2022;407:1881–90. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. Matthews J, Bhanderi S, Mitchell H, et al. Diaphragmatic herniation following esophagogastric resectional surgery: an increasing problem with minimally invasive techniques?: post-operative diaphragmatic hernias. Surg Endosc. 2016;30:5419–27. Additional Declarations No competing interests reported. Supplementary Files SupplementaryVideo1.mp4 SupplementaryVideo2.mp4 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Apr, 2024 Editor assigned by journal 18 Apr, 2024 Submission checks completed at journal 18 Apr, 2024 First submitted to journal 15 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4267983","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":293043048,"identity":"7f635321-92b1-4171-9386-d39ab167e8ef","order_by":0,"name":"Shingo Kanaji","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYBACCRDB2CDBwA/mHGBIgMkwE9Qi2UCiFgYGgwNoWnACyfazBz/+3GGRZ3zt8MEbDGds8vgZeAwYftQwsJvj0CLNk5cszXtGotjsdlqyBcONtGLJBh4Dxp5jDMyWDdi1yDHkGEgztkkkbrudYybB8OFw4ob7bwwYeBsYmEFOxaqF/43xz59ALZtn538Da9l/AGjLXzxapCWAhvMCtWyQzmGTYLgBtAXoF2Z8tkjOeGNmDdIy43aasUXCmbRiiQNsBYdljkng9IvE+Rzjmz/b6hL7Zyc/vPHhGDDEGpg3PnxTY5OMK8RQQQKUBjpJItmAKC3IwI50LaNgFIyCUTBMAQAT/1g2N2vswwAAAABJRU5ErkJggg==","orcid":"","institution":"Kobe University","correspondingAuthor":true,"prefix":"","firstName":"Shingo","middleName":"","lastName":"Kanaji","suffix":""},{"id":293043049,"identity":"94cae48c-ddd0-4e38-beb8-8c19315a0743","order_by":1,"name":"Naoki Urakawa","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Naoki","middleName":"","lastName":"Urakawa","suffix":""},{"id":293043050,"identity":"a8e7c33a-99b0-4dda-b02c-a53d5bb09d22","order_by":2,"name":"Hitoshi Harada","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Hitoshi","middleName":"","lastName":"Harada","suffix":""},{"id":293043051,"identity":"1ad2bfe7-2837-48fd-950c-93aa802a16e2","order_by":3,"name":"Atsushi Shimada","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Atsushi","middleName":"","lastName":"Shimada","suffix":""},{"id":293043052,"identity":"1a30ac1e-bd79-4ef1-9a96-c928a10bba0f","order_by":4,"name":"Yasufumi Koterazawa","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Yasufumi","middleName":"","lastName":"Koterazawa","suffix":""},{"id":293043053,"identity":"bfeb0466-5bd6-4acb-8341-4163472328f7","order_by":5,"name":"Ryuichiro Sawada","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Ryuichiro","middleName":"","lastName":"Sawada","suffix":""},{"id":293043054,"identity":"4b73bf1b-6fb1-4e5d-9d16-b4662c1fdfbd","order_by":6,"name":"Hironobu Goto","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Hironobu","middleName":"","lastName":"Goto","suffix":""},{"id":293043055,"identity":"7b5f1e9c-ac44-411b-8414-bf6ef10ad7a0","order_by":7,"name":"Hiroshi Hasegawa","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Hasegawa","suffix":""},{"id":293043056,"identity":"bdf38db7-5bb0-43e0-9684-1997f926e55d","order_by":8,"name":"Kimihiro Yamashita","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Kimihiro","middleName":"","lastName":"Yamashita","suffix":""},{"id":293043057,"identity":"ac628e83-9255-4eff-9928-1e98efad36c0","order_by":9,"name":"Takeru Matsuda","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Takeru","middleName":"","lastName":"Matsuda","suffix":""},{"id":293043058,"identity":"24b9876a-3bfc-4347-8bcd-7a33ff9f92f7","order_by":10,"name":"Taro Oshikiri","email":"","orcid":"","institution":"Ehime University","correspondingAuthor":false,"prefix":"","firstName":"Taro","middleName":"","lastName":"Oshikiri","suffix":""},{"id":293043059,"identity":"cb80aaa2-021a-4d1d-97a1-d2d2fbcb5469","order_by":11,"name":"Yoshihiro Kakeji","email":"","orcid":"","institution":"Kobe University","correspondingAuthor":false,"prefix":"","firstName":"Yoshihiro","middleName":"","lastName":"Kakeji","suffix":""}],"badges":[],"createdAt":"2024-04-15 07:35:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4267983/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4267983/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55510542,"identity":"a614097d-5c47-4454-8c4b-c13139474cd1","added_by":"auto","created_at":"2024-04-29 12:29:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":300012,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of the surgical view under the open left diaphragm method\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/535f6c515f138a926568270a.png"},{"id":55510544,"identity":"d62c0cd6-bd78-491e-a89d-7df5cfba041c","added_by":"auto","created_at":"2024-04-29 12:29:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1289659,"visible":true,"origin":"","legend":"\u003cp\u003eThe technique for the open left diaphragm method during total gastrectomy with an esophageal invasion length of 4 cm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. \u003c/strong\u003eAn incision was made in the left diaphragm using a 45-mm stapler device. \u003cstrong\u003eb. \u003c/strong\u003eDuring mediastinal lymph node dissection and reconstruction, the surgical view of the mediastinum was secured by lifting the separated diaphragm using the thread and internal organ retractor. \u003cstrong\u003ec.\u003c/strong\u003e In this case, the positive oral margin required additional resection of the distal esophagus, which was separated from the esophagus at a total of 6 cm from the esophagogastric junction and reconstructed. \u003cstrong\u003ed, e.\u003c/strong\u003e A soft silicone drain was placed into the left thoracic cavity under laparoscopic observation. \u003cstrong\u003ef\u003c/strong\u003e. The left diaphragmatic opening was closed using a nonabsorbable suture.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/a096e8591ed857d04e1ecd02.png"},{"id":55510545,"identity":"cdd9e214-5d2b-4ad3-8afd-d8322a8b1303","added_by":"auto","created_at":"2024-04-29 12:29:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":839883,"visible":true,"origin":"","legend":"\u003cp\u003eReoperation in a patient who developed anastomotic leakage with the open left diaphragm method\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea.\u003c/strong\u003e Preoperative esophagogastric endoscopy showed a Siewert type II tumor with an esophageal invasion length of 3 cm, with the esophagus being dissected 5 cm orally from the esophagogastric junction. \u003cstrong\u003eb.\u003c/strong\u003e Successful y-shaped overlap esophagogastric tube reconstruction. \u003cstrong\u003ec.\u003c/strong\u003e On the fourth postoperative day, the patient suddenly complained of chest and back pain and was diagnosed with anastomotic leakage on computed tomography. Owing to severe back pain, the patient could not undergo computed tomography in the supine position. \u003cstrong\u003ed.\u003c/strong\u003e During reoperation, the left thoracic cavity could be easily approached by removing the suture threads that sealed the diaphragm. \u003cstrong\u003ee.\u003c/strong\u003e Under endoscopic observation, the anastomotic leakage site was identified and repaired with additional sutures. \u003cstrong\u003ef.\u003c/strong\u003e Thoracic drains were placed under laparoscopic observation\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/f533b9896f8ffdcd84486e6a.png"},{"id":55511642,"identity":"03690ed4-0eaf-4e58-820b-c945a9cac006","added_by":"auto","created_at":"2024-04-29 12:37:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3998242,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/8609a18f-28e1-4576-bc77-20d7da61b655.pdf"},{"id":55510582,"identity":"1672198b-477d-43ee-813b-a6a7fea33898","added_by":"auto","created_at":"2024-04-29 12:29:38","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":234445615,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideo1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/eb1a0f7cad588b03285e465b.mp4"},{"id":55510581,"identity":"50ae6e87-3c99-45bd-8e00-f690a2da773d","added_by":"auto","created_at":"2024-04-29 12:29:35","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":159506195,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideo2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4267983/v1/72a9dd576f1fa3054be1dba6.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOpen left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIncidence rates of esophagogastric junction adenocarcinoma have been increasing globally, including in Japan [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In this regard, proximal gastrectomy (PG) with lower esophagectomy (PGLE) and lymph node dissection has been considered an oncologically adequate treatment approach for Siewert type II adenocarcinoma with an esophageal invasion length of 2.1\u0026ndash;4.0 cm [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and the proximal margin is recommended to be \u0026gt;\u0026thinsp;2.0 cm [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Regarding open surgery, one study showed that left-open thoracotomy is not recommended for gastric cancers with an esophageal invasion length of \u0026lt;\u0026thinsp;3 cm due to the increased risk of developing respiratory complications compared to the transhiatal approach [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, limited evidence is available on the length of esophageal invasion of gastric cancer that can be safely handled via the laparoscopic transhiatal approach. Furthermore, whether the thoracoscopic, laparoscopic, or combined approach is less invasive in laparoscopic surgery for PGLE or total gastrectomy (TG) with lower esophagectomy (TGLE) remains debatable. A Japanese prospective nationwide multicenter study comparing the postoperative complications of the transthoracic and transhiatal approaches for esophagogastric junction adenocarcinoma found that both approaches showed high rates of anastomotic leakage (12.5% vs. 12.0%, respectively) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, cases of grade IV severe anastomotic leakage were observed only in the transhiatal group and not in the transthoracic group (2.7% vs. 0%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, the aforementioned study found that these approaches were associated with extremely high anastomotic leakage rates (4/21, 19.0%) despite the small number of patients who underwent transhiatal gastrectomy with minimally invasive surgery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The transhiatal approach with minimally invasive surgery is exceedingly difficult given that it requires a high degree of proficiency in suturing within a confined space, which may lead to high incidence rates of anastomotic leakage. Moreover, drainage may be difficult once an anastomotic leakage occurs, which may result in severe complications. Considering the technical difficulties and risks for complications associated with reconstruction via the transhiatal approach, the Ivor Lewis or McKeown procedures for esophagectomy may be considered in patients with esophagogastric tumors. However, considering the low oncological need for a transthoracic approach for Siewert type II tumors with an esophageal invasion length of \u0026le;\u0026thinsp;4.0 cm, these procedures would be excessively invasive compared to laparoscopic PGLE. Takiguchi et al. had been the first to report on a six-case series that used the laparoscopic approach via an opening in the left diaphragm, which provided a good surgical space and a clear view for mediastinal lymph node dissection and reconstruction in patients with Siewert type II adenocarcinoma [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Similarly in 2014, we also introduced the open left diaphragm method for Siewert type II or type III adenocarcinomas with an esophageal invasion length of \u0026le;\u0026thinsp;4.0 cm, depending on the cases. However, although our approach provides a clear view of the inferior mediastinum, making large horizontal incisions in the diaphragm can be challenging given its potential to decrease thoracic movement due to paralysis of the diaphragmatic nerve, resulting in increased respiratory complications. Hence, herein, we aimed to evaluate the feasibility and safety of the laparoscopic transhiatal approach with the open left diaphragm method using a stapler device during PGLE or TGLE for Siewert type II/III adenocarcinomas with esophageal invasion.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective study assessed the clinical outcomes of patients who underwent laparoscopic transhiatal PGLE or TGLE with or without the open left diaphragm method for Siewert type II/III adenocarcinomas with esophageal invasion from April 2013 to December 2021 at Kobe University. In 2014, we introduced the open left diaphragm method, which was initially performed at the discretion of the surgeon in cases with high anastomotic difficulty. Since 2018, we have used this method for all laparoscopic transhiatal approaches. All patients were preoperatively diagnosed based on endoscopy and computed tomography scans. All tumors examined in this study were confirmed to be adenocarcinomas of Siewert type II/III with an esophageal invasion length of \u0026le;\u0026thinsp;4.0 cm via preoperative examination. Throughout this consecutive period, no subtotal esophagectomy via the Ivor Lewis or McKeown procedure was performed for esophagogastric junction adenocarcinomas with an esophageal invasion length of \u0026lt;\u0026thinsp;4 cm. For Siewert type II/III adenocarcinomas with an esophageal invasion length of \u0026lt;\u0026thinsp;4 cm, the first choice was PG, with TG being performed in cases where the tumor had\u0026thinsp;\u0026gt;\u0026thinsp;4 cm of extension toward the stomach. In all patients, preoperative endoscopic marking was performed by placing two clips on the proximal edge of the tumor 1\u0026ndash;7 days before surgery. At least one surgeon qualified to perform laparoscopic gastrectomy according to the Endoscopic Surgical Skill Qualification System in Japan [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] participated in all of the surgeries. In all patients, lymph node dissection and reconstruction during laparoscopic PGLE or TGLE were performed using the same established method. The Japanese Classification of Gastric Carcinoma (3rd English edition) was used for TNM staging [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study was approved by the ethics committee of Kobe University (No. B210278). All patients provided written informed consent to publish anonymized surgery-related data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedures\u003c/h2\u003e \u003cp\u003eAll patients underwent laparoscopic PGLE or TGLE as follows. Under general anesthesia, the patient was placed in the reverse Trendelenburg position with the legs apart. The surgeon and the first assistant stood on the patient\u0026rsquo;s right and left sides, respectively, while the camera operator stood between the patient\u0026rsquo;s legs. The first 12-mm trocar was inserted through an umbilical incision via the open surgical method, a 10-mm flexible laparoscope (Olympus Optical, Tokyo, Japan) was inserted through the port, and pneumoperitoneum was established. The second 12-mm trocar was inserted from inside the right costal margin, after which a 5-mm trocar was inserted from outside the right costal margin. Another 5-mm trocar was inserted 20 mm above and left of the umbilicus, and the third 12-mm trocar was inserted from the left costal margin. The fourth 12-mm trocar was inserted from the epigastric region. A constant intra-abdominal pressure of 10 mmHg was maintained during the procedure. According to the Japanese Gastric Cancer Treatment Guidelines 2020 (5th edition), lymph node dissection was performed based on tumor location. Regarding the lower mediastinal lymph node, the following lymph nodes were dissected transhiatally: tumors within the submucosa, 110, 111, and 112; tumors deeper than the submucosa, 110, 111, and 112 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eLaparoscopic transhiatal procedure\u003c/h2\u003e \u003cp\u003eThe following technique was used for the open left diaphragm method (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Supplementary Video 1). First, the left diaphragmatic leg was separated before performing mediastinal lymph node dissection. Second, an incision was made in the left diaphragm using a 45-mm stapler device (Signia\u0026trade; with a Tri-staple, 45-mm camel cartridge; Medtronic, Dublin, Ireland) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). During mediastinal lymph node dissection and reconstruction, the surgical view of the mediastinum was secured by lifting the separated diaphragm or pericardial sac using the surgical retractor (Endo Retract\u0026trade; II 10 mm instrument; Medtronic, Dublin, Ireland) via the additional epigastric port or thread and internal organ retractor (B. Braun, Tokyo, Japan) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, c). In patients who did not undergo surgery via the open left diaphragm method, the diaphragm was incised longitudinally, the bilateral diaphragmatic legs were separated, and, as a rule, the thoracic cavity was not opened.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn all patients, an intraoperative endoscopic examination was performed to confirm the proximal edge of the tumor by locating the marking clips placed preoperatively and determining the oral cutting line at least 20 mm away from the clips. The lower esophagus was transected from front to back at least 30 mm proximal to the cutting line using an endoscopic linear stapler (Signia\u0026trade; with a Tri-staple, 60-mm purple cartridge) from the inside right port of the surgeon. Reconstruction after PGLE or TGLE was performed following a previously reported procedure [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A soft silicone drain was usually placed into the left thoracic cavity between the eighth and ninth or seventh and eighth ribs under laparoscopic observation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). Thereafter, a towel was folded over the dorsal aspect of the left thoracic cavity to place the drain slightly dorsal to the thoracic cavity, over the diaphragm, and behind the anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee). Finally, the opened left diaphragm was closed by intracorporeal suturing using 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Ethibond (Ethicon) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical complications\u003c/h2\u003e \u003cp\u003eData on surgical complications and postoperative clinical courses were retrospectively retrieved from the database. All postoperative complications (major and minor) were graded according to the Clavien\u0026ndash;Dindo classification [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up protocol\u003c/h2\u003e \u003cp\u003eAll patients underwent follow-up examinations, including regular physical and laboratory blood tests, 3, 6, and 12 months after surgery. Postoperative respiratory complications in the late phase were evaluated through computed tomography performed 6 and 12 months after surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using JMP software version 8.0 (SAS Institute, Cary, NC, USA). Continuous variables were presented as medians (ranges), and analyses were conducted using Fisher\u0026rsquo;s exact and Mann\u0026ndash;Whitney U tests. A \u003cem\u003eP\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered indicative of statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 55 patients underwent surgery via the laparoscopic transhiatal approach (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), among whom 42 and 13 did and did not undergo surgery via the open left diaphragm method, respectively. No significant difference in patient background was observed between patients who did and did not undergo surgery via the open left diaphragm method; however, those in the open left diaphragm group tended to have slightly longer median length of clinical esophageal invasion and esophagectomy than those in the non-open left diaphragm group. Approximately 75% of the patients in the open left diaphragm group and non-open left diaphragm group underwent PG (74% and 77%), whereas approximately 25% underwent TG (26% and 24%). One patient had a history of open surgery (i.e., abdominoperineal resection), whereas another patient simultaneously underwent laparoscopic rectal resection, both of whom were included in the open left diaphragm group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients with esophagogastric junction adenocarcinoma who underwent gastrectomy with lower esophagectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eOpen left diaphragm method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (47\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (52\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male/female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (81%)/8 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (85%)/2 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.4 (16.4\u0026ndash;31.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4 (16.6\u0026ndash;31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG-PS, 0\u0026ndash;1/2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (83%)/7 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(92%) / 1(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS, 1\u0026ndash;2/3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (76%)/10 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (69%)/4 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI, 0/1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (52%)/20 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (62%)/5 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical tumor depth\u003csup\u003e\u0026dagger;\u003c/sup\u003e, T1/T2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (40%)/25 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (46%)/7 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage\u003csup\u003e\u0026dagger;\u003c/sup\u003e, I\u0026ndash;II/III\u0026ndash;IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (74%)/11 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (85%)/2 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant chemotherapy, Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (36%)/27 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (31%)/9 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological tumor depth\u003csup\u003e\u0026dagger;\u003c/sup\u003e, T1/T2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (50%)/21 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (62%)/5 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological stage\u003csup\u003ea\u003c/sup\u003e, I\u0026ndash;II/III\u0026ndash;IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (57%)/18 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (62%)/5 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of procedure: PG/TG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (74%)/11 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (77%)/3 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of the clinical esophageal invasion, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (5\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of the resected esophagus, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (30\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (20\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Classified by TNM classification 7th edition (International Union Against Cancer).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eContinuous variables are presented as median and range.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: BMI, body mass index; ECOG-PS, Eastern Cooperative Oncology Group performance status; ASA-PS, American Society of Anesthesiologists physical status; PG, proximal gastrectomy; TG, total gastrectomy\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe surgical outcomes of the patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Notably, the median operative time was slightly shorter (although not significantly) in the open left diaphragm group than in the non-open left diaphragm group (369 vs. 482 min; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.07). Moreover, intraoperative left thoracic drain placement was more common in the open left diaphragm group than in the non-open left diaphragm group (88 vs. 31%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), whereas grade\u0026thinsp;\u0026ge;\u0026thinsp;II postoperative respiratory complications were significantly more common in the latter than in the former (17% vs. 46%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03). Most respiratory complications in both groups were either pleural effusion or atelectasis. Grade\u0026thinsp;\u0026ge;\u0026thinsp;II anastomotic leakage was observed in two patients each in the open and non-open left diaphragm groups. One case each in the open and non-open left diaphragm groups required reoperation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Supplementary Video 2), both of whom underwent surgery via the laparoscopic approach. Another case in the open left diaphragm group required reoperation for left diaphragmatic hernia and postoperative bowel obstruction. Although no difference in the length of hospital stay was observed between the two groups, patients in the non-open left diaphragm group who received conservative treatment for suture insufficiency had the longest postoperative stay (i.e., 112 days). None of the patients in both groups died or experienced severe grade IV complications, including those requiring postoperative respiratory support or tracheotomy. No differences in the observation period and Eastern Cooperative Oncology Group performance status (ECOG-PS) 12 months after surgery were observed between the open and non-open left diaphragm groups (ECOG-PS: 0.07\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.07 vs. 0.31\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.63; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.14). None of the patients in both groups showed any late complications within 12 months after surgery, including postoperative diaphragmatic herniation and diaphragmatic elevation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical outcomes of patients with esophagogastric junction adenocarcinoma who underwent gastrectomy with lower esophagectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eOpen left diaphragm method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP-\u003c/em\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e369 (244\u0026ndash;680)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e482 (255\u0026ndash;565)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (0\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (0\u0026ndash;370)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion, Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2%)/41 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8%)/12 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacement of a thoracic drain, Yes/No\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (88%)/5 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(31%) / 9(69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to laparotomy or thoracotomy, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory complications\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative severe complication\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiaphragmatic hernia\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall bowel obstruction\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory use after surgery, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTracheotomy or tube tracheotomy, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay, days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (7\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (12\u0026ndash;112)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre- and postoperative changes in ECOG-PS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservation period, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (6\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (7\u0026ndash;115)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Grade II or IIIa according to the Clavien\u0026ndash;Dindo Classification\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Grade IIIb according to the Clavien\u0026ndash;Dindo Classification\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: ECOG-PS, Eastern Cooperative Oncology Group performance status\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the feasibility and safety of the laparoscopic transhiatal approach through the open left diaphragm method using a stapler device during PGLE or TGLE for Siewert type II/III adenocarcinomas with esophageal invasion. Notably, the open left diaphragm group showed no severe grade IV or V postoperative complications while exhibiting lower incidence rates of respiratory complications than the non-open left diaphragm group. Moreover, the open left diaphragm group showed a shorter (although not significantly) operative time and lower incidence rates of anastomotic leakage than the non-open left diaphragm group. The open left diaphragm method expanded the operative field in the mediastinum, encompassing the left thoracic cavity. This spacious area facilitated easy and safe reconstruction, although continuous and careful monitoring of blood gases is essential owing to lung deflation caused by pneumoperitoneum. However, we observed that maintaining a pneumoperitoneum pressure of 10 mmHg did not interfere with positive ventilation or blood gas levels in all cases reported herein.\u003c/p\u003e \u003cp\u003eAn esophageal invasion length of \u0026lt;\u0026thinsp;4 cm in length has been associated with low frequencies of lymph node involvement in the upper and middle mediastinum, rendering transhiatal reconstruction oncologically sufficient [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, anastomotic risks associated with the narrow space encountered during transhiatal reconstruction have been one of the primary reasons why some institutes initially select the thoracoscopic approach for reconstruction in cases with Siewert type II/III tumors with esophageal invasion. Although a longitudinal incision through the esophageal hiatus widens the surgical view in the lower mediastinum, a large horizontal incision through the left diaphragm provides an even larger field of view than a longitudinal incision through the esophageal hiatus, as the pericardial sac is no longer an obstacle. This enables reconstruction in a surgical field where the left thoracic cavity appears to be continuous with the abdominal cavity.\u003c/p\u003e \u003cp\u003eHowever, several concerns exist regarding creating a sizable horizontal incision through the left diaphragm. The first concern involves the possibility of increased rates of postoperative diaphragmatic hernias. Incomplete diaphragmatic closures have resulted in one case (2%) of diaphragmatic hernia.\u003c/p\u003e \u003cp\u003eEstimates have shown that approximately 10% of patients who undergo minimally invasive esophagectomies develop postoperative diaphragmatic hernias [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The hiatus must be closed properly to prevent diaphragmatic hernias; unfortunately, this can be quite challenging to accomplish laparoscopically given that the diaphragm can be easily torn during repair using a thread. To overcome this problem, continuous suturing along with a staple line had been introduced. The suture line made by the stapling device can also function as a guideline, similar to a fastener.\u003c/p\u003e \u003cp\u003eAnother concern is that a large horizontal diaphragmatic incision would increase respiratory complications, most of which, however, include atelectasis and pleural effusion. Nonetheless, these complications were observed only in the initial period when no thoracic drain was placed intraoperatively and were no longer observed after the left thoracic drain was placed laparoscopically. Furthermore, no evidence of diaphragmatic elevation would raise suspicion of diaphragmatic nerve palsy, including computed tomography images taken 3, 6, and 12 months after surgery. Although detailed respiratory function tests were not performed, opening the diaphragm did not result in a deterioration of ECOG-PS or only showed a negligible decrease, if any.\u003c/p\u003e \u003cp\u003eOpening the left thoracic cavity increased the risk of developing left pyothorax or other problems in the event of an anastomotic leakage. However, our findings showed that the incidence rates of anastomotic leakage were lower in the open left diaphragm group than in the non-open left diaphragm group. Nonetheless, this result can be attributed to the good field of view during reconstruction and adequate confirmation of the entire anastomotic site before surgery. However, given that severe anastomotic leakage can occur with the transhiatal approach [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], knowledge on how to recover from it to prevent severe pyothorax is also essential. In some cases of left pyothorax, the patient\u0026rsquo;s vital signs would be unstable, as demonstrated by hypotension and respiratory failure due to septic shock. In such cases, thoracoscopic drainage using a thoracoscope in the left lateral or prone position is expected to be complicated. In cases of anastomotic leakage after opening the left diaphragm, the left thoracic cavity can be easily approached by removing the suture threads that close the diaphragm (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). In both patients that underwent reoperation, additional sutures at the leak and drainage sites of the left thoracic cavity were possible. We have not yet experienced a case in which anastomotic leakage developed in the abdominal cavity due to suture closure of the diaphragm after reoperation.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, this was a single-center study with a small cohort. However, the short- and mid-term surgical outcomes of our novel technique were meaningful considering the rarity of Siewert type II/III adenocarcinomas with esophageal invasion. Second, we did not compare the outcomes between our technique and other approaches, such as the transhiatal approach without diaphragmatic incision and the thoracoscopic approach in a large cohort. Third, in the early phase, the open left diaphragm method was applied only to cases with high anastomotic difficulty, suggesting a potential historical bias. Further studies are warranted to investigate which approach is least invasive for patients undergoing lower esophagectomy for Siewert type II/III tumors with esophageal invasion.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study showed that transhiatal lower esophagectomy with gastrectomy via the open left diaphragm method is a minimally invasive and safe approach that can be employed for Siewert type II/III esophagogastric junction adenocarcinomas with an esophageal invasion length of \u0026le;\u0026thinsp;4 cm.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e We certify that there is no actual or potential conflict of interest in relation to this article. All authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman rights statement and informed consent:\u003c/strong\u003e All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for participating in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eSK conceptualized and designed the study, participated in the sequence alignment, and drafted the manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRS,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eYK, and AS were involved in the acquisition of data. HG, HH, KY, and TO contributed to the analysis and interpretation of data. TK, NU, HH, and TM participated in critical revision of the manuscript. YK conceived the study, participated in its design and\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ecoordination, and helped draft the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamashita H, Seto Y, Sano T, et al. Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma. Gastric Cancer. 2017;20:69\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurokawa Y, Takeuchi H, Doki Y, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study. Ann Surg. 2021;274:120\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMine S, Sano T, Hiki N, et al. Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction. Br J Surg. 2013;100:1050\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSasako M, Sano T, Yamamoto S, et al. Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial. Lancet Oncol. 2006;7:644\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMine S, Kurokawa Y, Takeuchi H, et al. Postoperative complications after a transthoracic esophagectomy or a transhiatal gastrectomy in patients with esophagogastric junctional cancers: a prospective nationwide multicenter study. Gastric Cancer. 2022;25:430\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakiguchi S, Miyazaki Y, Shinno N, et al. Laparoscopic mediastinal dissection via an open left diaphragm approach for advanced Siewert type II adenocarcinoma. Surg Today. 2016;46:129\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanigawa N, Lee SW, Kimura T, et al. The endoscopic surgical skill qualification system for gastric surgery in Japan. Asian J Endosc Surg. 2011;4:112\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJapanese Gastric Cancer Association. Japanese classification of gastric carcinoma. 3rd ed. Gastric Cancer. 2011;14:101\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJapanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018. 5th ed. Gastric Cancer. 2020;24:1\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaji S, Suzuki S, Harada H, et al. Comparison of two- and three-dimensional display for performance of laparoscopic total gastrectomy for gastric cancer. Langenbecks Arch Surg. 2017;402:493\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanaji S, Suzuki S, Yamamoto M, et al. Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction. Langenbecks Arch Surg. 2022;407:1881\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatthews J, Bhanderi S, Mitchell H, et al. Diaphragmatic herniation following esophagogastric resectional surgery: an increasing problem with minimally invasive techniques?: post-operative diaphragmatic hernias. Surg Endosc. 2016;30:5419\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"adenocarcinoma, esophagogastric junction, laparoscopy, transhiatal reconstruction, lower esophagectomy, Siewert type II/III adenocarcinoma, open left diaphragm method esophagectomy","lastPublishedDoi":"10.21203/rs.3.rs-4267983/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4267983/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite being oncologically acceptable for esophagogastric junction adenocarcinoma with an esophageal invasion length of 3\u0026ndash;4 cm, the transhiatal approach has not yet become a standard method given the difficulty of reconstruction in a narrow space and the risk of severe anastomotic leakage. This study aimed to clarify the safety and feasibility of the open left diaphragm method during the transhiatal approach for esophagogastric junction adenocarcinoma.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study compared the clinical outcomes of patients who underwent proximal or total gastrectomy with lower esophagectomy for Siewert type II/III adenocarcinomas with esophageal invasion via the laparoscopic transhiatal approach with or without the open left diaphragm method from April 2013 to December 2021.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 42 and 13 patients did and did not undergo surgery with the open left diaphragm method, respectively. The median operative time was only slightly shorter in the open left diaphragm group than in the non-open left diaphragm group (369 vs. 482 min; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.07). Grade\u0026thinsp;\u0026ge;\u0026thinsp;II postoperative respiratory complications were significantly less common in the open left diaphragm group than in the non-open left diaphragm group (17% vs. 46%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03). Neither group had grade\u0026thinsp;\u0026ge;\u0026thinsp;IV anastomotic leakage, and two cases of anastomotic leakage requiring reoperation were drained using the left diaphragmatic release technique.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTranshiatal lower esophagectomy with gastrectomy using the open left diaphragm method is minimally invasive and safe, highlighting its advantages for Siewert type II/III esophagogastric junction adenocarcinoma with an esophageal invasion length of \u0026le;\u0026thinsp;4 cm.\u003c/p\u003e","manuscriptTitle":"Open left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 12:29:22","doi":"10.21203/rs.3.rs-4267983/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-23T16:14:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-19T03:41:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-18T15:32:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-04-15T07:33:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"056bdf96-4be8-4c8d-ade8-93a48b59b231","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-22T04:14:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-29 12:29:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4267983","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4267983","identity":"rs-4267983","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}