Orvil

D1+ lymphadenectomy was performed in LSTG16; details of this surgical procedure have been described previously18. During lymph node dissection, several distal branches of the short gastric artery were divided, preserving at least one branch near the cardia. Depending on tumour location, the posterior gastric artery was sometimes divided. Intraoperative gastroscopy was performed to confirm the location of the tumour and marking clips were placed before surgery. In some patients in whom the boundary of the tumour was very close to the cardia and/or fornix, cautery markings were made by endoscopy on the day before surgery for use as landmarks instead of clips19. The stomach was transected with an endoscopic linear stapler, leaving a very small remnant stomach. Intraoperative frozen‐section analysis of the proximal surgical margin was performed in all patients. After lymph node dissection, a Roux‐en‐Y reconstruction was created via an antecolic route. Gastrojejunostomy was performed using an endoscopic linear stapler or a 25‐mm circular stapler with a perorally inserted anvil (Orvil®; Covidien, Mansfield, Massachusetts, USA). A side‐to‐side jejunostomy was performed approximately 30–40 cm distal from the gastrojejunal anastomosis. Since 2010, after creation of the anastomosis the Petersen defect has been closed with a non‐absorbable suture.

Over the 11‐year period, oesophagectomies were performed by ten specialist upper gastrointestinal consultant surgeons, or trainees under supervision, and classified as open, minimally invasive or hybrid. The decision regarding surgical approach was at the discretion of the consultant surgeon. Completely minimally invasive procedures were introduced in 2008. Anastomotic techniques included hand‐sewn, circular stapled, OrVil™ (Covidien, Mansfield, MA, USA) and semimechanical anastomoses. Postoperative nutritional support was used routinely via feeding jejunostomy, unless, for technical reasons, nasojejunal feeding or total parenteral nutrition was needed. After surgery, all patients were managed initially in a critical care unit before transfer to standard ward care when considered fit. R1 resections were those in which the tumour was present microscopically within 1 mm of the circumferential, distal or proximal margins, as described by the Royal College of Pathologists22; R2 resections were those in which tumour could not be removed completely, leaving macroscopic residual tumour.