Fundus Rotation Gastroplasty vs. Kirschner-Akiyama Gastric Tube in Esophageal Resection: Comparison of Perioperative and Long-Term Results

Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG II): thoracoabdominal or abdominal approach?

BACKGROUND

The optimal surgical approach for adenocarcinoma directly at the esophagogastric junction (AEG II) is still under debate. This study aims to evaluate the differences between right thoracoabdominal esophagectomy (TAE) (Ivor-Lewis operation) and transhiatal extended gastrectomy (THG) for AEG II.

METHODS

From a prospective database, 242 patients with AEG II (TAE, n = 56; THG, n = 186) were included and analyzed according to characteristics and perioperative morbidity and mortality and overall survival (chi-square, Mann-Whitney U, log-rank, Cox regression).

RESULTS

Groups were comparable at baseline with exception of age. Patients older than 70 years were more frequently resected by THG (p = 0.003). No differences in perioperative morbidity (p = 0.197) and mortality (p = 0.711) were observed, including anastomotic leakages (p = 0.625) and pulmonary complications (p = 0.494). There was no significant difference in R0 resection (p = 0.719) and number of resected lymph nodes (p = 0.202). Overall median survival was 38.4 months. Survival after TAE was significantly longer than after THG (median OS not reached versus 33.6 months, p = 0.02). Multivariate analysis revealed pN-category (p < 0.001) and type of surgery (p = 0.017) as independent prognostic factors. The type of surgery was confirmed as prognostic factor in locally advanced AEG II (cT 3/4 or cN1), but not in cT1/2 and cN0 patients.

CONCLUSIONS

Our single-center experience suggests that patients with (locally advanced) AEG II tumors may benefit from TAE compared to THG. For further evaluation, a randomized trial would be necessary.

Expression of MMP9, SERPINE1 and miR-134 as prognostic factors in esophageal cancer

Esophageal cancer (EC) is a malignant tumor with a typically poor prognosis for patients. It is well known that certain microRNA (miRNA/miR) genes can regulate other genes responsible for carcinogenesis. In the present study, a group of these genes (miR-21, miR-134, miR-205 and miR-495) and genes connected with cancer-related pathways (MET, MMP9, PDGFA and SERPINE1) were chosen for analysis in order to find a potential correlation between their expression and the clinicopathological factors of EC. Esophageal tumors and adjacent non-cancerous tissue specimens were collected from a total of 63 patients and embedded in paraffin. Commercial arrays were used on KYSE-30, KYSE-150 and KYSE-270 EC cell lines in order to find genes of different expression profiles compared with those acquired from the control Het-1A cell line. Quantitative polymerase chain reaction was used on formalin-fixed, paraffin-embedded samples in order to analyze the expression of the genes chosen in the earlier step. The results were analyzed by the Kruskal-Wallis and Mann-Whitney U tests, Spearman's rank correlation coefficient, Kaplan-Meier methods and the long-rank test. Only miR-495 was not expressed in the analyzed samples. The expression of MMP9 and SERPINE1 was significantly coefficient with age range (P=0.011 and P=0.044, respectively) according to the Kruskal-Wallis test. The Spearman's rank-order correlation measurement showed that there was a coefficient correlation between age and miR-134 expression. The same measurement demonstrated a correlation between age range and MMP9 expression. The expression of miR-134 and MMP9 were also found to be correlated. In all cases, a value of P<0.049 was recorded. Overall, the present study demonstrated that MMP9, SERPINE1 and miR-134 were the most prognostic genes in Caucasian patients with EC.

Modifications in retrosternal reconstruction after oesophagogastrectomy may reduce the incidence of anastomotic leakage

OBJECTIVES

The retrosternal route has been an alternative for oesophageal reconstruction after oesophagectomy. But the longer route and the higher incidence for cervical anastomotic leakage compared with the posterior mediastinal approach have always hampered its wider use. However, with the recent work reported by Chen and colleagues, the anterior route has been confirmed to provide the shortest physiological distance for oesophageal reconstruction using the stomach. Furthermore, improving the original surgical procedures seemed to improve outcomes. This research aims to evaluate whether modification of the original surgical standard of alimentary tract reconstruction after oesophagectomy can reduce the incidence of anastomotic leakage.

METHODS

One hundred and two patients were divided into the research group and the control group. Subjects in the research group received the improved three-incision oesophagectomy (right chest/belly/left neck) after which the alimentary tract reconstruction was achieved by using a gastric conduit positioned through the retrosternal route. Patients in the control group received the original surgical procedures. Parameters such as the incidence of anastomotic leakage, pneumonia, length of hospital stay, ICU stay and pathological staging were compared between the two groups.

RESULTS

No significant statistical differences were found in parameters such as age, gender, height, weight, comorbidities, location and length of the tumour and final pathological staging of the patients between the two groups. Similarly, intraoperative and postoperative information such as operating time, hospital stay, pneumonia and volume of blood loss are comparable between the two groups. The incidence of anastomotic leakage was, respectively, 4.84% (3/62) in the research group and 20% (8/40) in the control group. The incidence of anastomotic leakage in the research group was lower than the one in the control group, and the difference was statistically significant (P = 0.037).

CONCLUSIONS

Modifications of the original surgical standard including expanding the retrosternal tunnel, widening the gastric tube, resection of the sternothyroid muscle and fixation of the gastric tube, contribute to decreasing the incidence of cervical anastomotic leakage.