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Recent advances in treatment for esophageal cancer have improved prognosis after esophagectomy, but they have led to an increased incidence of gastric conduit cancer. In most gastric conduit cancer patients who underwent retrosternal reconstruction, median sternotomy is performed, which is associated with a risk of postoperative bleeding and osteomyelitis; pain often negatively affects respiration. To avoid these problems, we developed thoracoscopic retrosternal gastric conduit resection in the supine position (TRGR-S) as new procedure. Methods We performed the first case of TRGR-S for a 75-year-old male with retrosternal gastric conduit cancer. He was placed in the supine position. Four ports were placed in the left chest wall. The gastric conduit was separated from the epicardium, sternum, and left brachiocephalic vein. Due to adhesions between the gastric tube and the right pleura, combined resection of the right pleura was performed. Next, pediculated jejunal reconstruction via the presternal route was performed. Results Because there were few adhesions in the left thoracic cavity, this approach provided safety and a good surgical view, and it was easy to recognize the landmark including epicardium, sternum, and left brachiocephalic vein leading to appropriate resection of the tissue. Furthermore, there were few restrictions on the operative angle for the forceps and operability was quite ergonomic. Moreover, the lungs can be noninvasively contracted via an artificial pneumothorax. The pathological diagnosis was signet ring cell carcinoma (pT1b, pN0, M0, pStage I), indicating R0 resection. There were no post-operative complications. Conclusion This approach does not require sternotomy, so it has less risk of postoperative bleeding and osteomyelitis. Due to fewer adhesions, this approach is safe and provides a good surgical view. TRGR-S is a safe, ergonomic, and reliable procedure for resection of retrosternal gastric conduit cancer. Video This is the video of the operation ‘TRGR-S’, which is the new procedure for the gastric conduit cancer. https://www.dropbox.com/s/2whnekgp73hw1lz/video%20for%20ISDE2020.mov?dl=0.

Reconstruction routes after esophagectomy include posterior mediastinal, retrosternal, and subcutaneous route. We have performed posterior mediastinal reconstruction, but this route has higher risks of gastro-tracheal fistula and hiatal hernia. To avoid these complications, now we take the retrosternal route as our first choice by creating the route laparoscopically before pulling-up gastric conduit. We report the successful and safe procedure. Methods We performed laparoscopic creation of retrosternal route in 13 thoracoscopic/robot-assisted minimally invasive esophagectomies since August 2019. In practice, a peritoneal incision at the dorsal side of the xiphoid process is started. Then, via 12 mm port on the surgeon's right hand inserted slightly to the right and cranial side of the umbilical camera port, we dissect loose connective tissues from the caudal side to the cranial side behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route and pleural injury rate during the procedure was examined. Results Thirteen cases were divided into two groups as early period group (seven cases) and later period group (six cases) respectively. The time required for route creation was 31.3 minutes(average) in the early period group, and 16.7 minutes in the later period group. There is tendency towards faster in later period group than in earlier one. The overall pleural injury rate was 15% (2 of 13 cases). Although it was difficult to determine the amount of bleeding, it was visually observed that the bleeding during the route creation was lower in the later period group than in the early period group. Conclusion The entire laparoscopic procedure to create retrosternal route makes it easier to observe and preserve the pleura and internal thoracic vessels compared to blind blunt dissection. As a conclusion, laparoscopic creation of retrosternal route for gastric conduit reconstruction is safe and feasible with good learning curve. Video https://www.dropbox.com/sh/p0wc3x46n33jp23/AADwiWHYIEUNUX6qZsERVIOga?dl=0.

Thoracoscopic esophagectomy in the prone position (TEP) for esophageal cancer is reported to have superiority in preserving postoperative respiratory function and reducing postoperative respiratory complications. In Japan, the majority of patients with esophageal cancer are smokers and have obstructive ventilation disorders. But, the feasibirity and safety of TEP for patients with low respiratory function is unclear. Objectives To clarify the feasibirity and safety of TEP for esophageal cancer patients with obstructive respiratory function. Methods The 95 patients with obstructive respiratory disorder who underwent TEP and gastric tube reconstruction via posterior mediastinal route for esophageal cancer from January 2016 to April 2019 were divided into the two groups, low respiratory function (LRF) group and the control group. Short-term outcomes were compared between two groups. Results The control group was 73 cases, and the LRF group was 22 cases. Propensity score matching using age, gender, cT, and cN as covariates was used to identify matched patients (22 per group) in both groups. There were no differences in operation time of overall and intrathoracic part, or blood loss in each group. In the postoperative complications, pneumonia (13.6% vs. 9.1%), recurrent laryngeal palsy (18.2% vs. 22.7%), anastomotic leakage (13.6% vs. 13.6%) and hospital stay (36.3 days vs 27.5 days) were no differences in both groups. Conclusion TEP can be feasible and safe for the patients with obstructive ventilation disorder and low respiratory function.