Postoperative complications after a transthoracic esophagectomy or a transhiatal gastrectomy in patients with esophagogastric junctional cancers: a prospective nationwide multicenter study

Appetite-preserving gastrectomy (APG) for esophagogastric junction cancer: preserving the residual stomach as an endocrine organ

BACKGROUND

Loss of appetite following gastric cancer surgery, particularly total gastrectomy, significantly impacts patient quality of life due to the removal of the ghrelin-secreting region. We developed appetite-preserving gastrectomy (APG), a modified total gastrectomy that preserves this region.

METHODS

Ten consecutive patients with esophagogastric junction cancer who were indicated for total gastrectomy and underwent APG between April 2023 and April 2024 were evaluated for early surgical outcomes, appetite, and changes in weight and body composition.

RESULTS

There were no postoperative complications of grade II or higher (Clavien-Dindo classification). Appetite, assessed using the Simplified Nutritional Appetite Questionnaire, showed no significant impairment at 3 months (14.5 points, P = 0.82) and 6 months (15 points, P = 0.44) postoperatively compared with preoperative values. Oral calorie intake was maintained at 3 months (1675 kcal, P = 0.97) and 6 months (1675 kcal, P = 0.22) postoperatively compared with preoperative levels. The patients' body weight decreased by 9.2% at 6 months postoperatively compared with preoperative values, but their lean body mass remained stable. Although a significant decrease in the blood Ghrelin levels was observed postoperatively, 53% and 60.4% of the preoperative levels was maintained at one month and 6 months, respectively.

CONCLUSIONS

APG is a safe procedure that preserves the residual stomach as an endocrine organ, maintains ghrelin secretion and appetite, and prevents muscle loss. However, further trials are required to compare the efficacy of APG with total gastrectomy in preventing postoperative appetite loss.

Effect of thoracic size on postoperative outcomes in transabdominal gastrectomy for Siewert type II/III adenocarcinoma of the esophagogastric junction

BACKGROUND

The surgery of adenocarcinoma of the esophagogastric junction (AEG) is a complex procedure that increases postoperative morbidity compared to distal gastric cancer. In this study, we included thoracic anatomical parameters of patients for the first time to investigate their impact on the postoperative outcomes of transabdominal gastrectomy for Siewert type II/III AEG.

METHODS

All patients with Siewert type II or III AEG of our institution who underwent transabdominal proximal or total gastrectomy from January 2015 to December 2022 were included in this study. We measured thoracic anatomical parameters on the level of the lower edge of the sternum using preoperative computer tomography. The anteroposterior diameter of the thorax was measured as the distance from the posterior edge of the sternum to the anterior edge of the spine, while the transverse diameter was the maximum distance between the ribs on both sides. Patients' data and postoperative details were retrospectively collected. Correlation between thoracic anatomical parameters with postoperative complications were analyzed.

RESULTS

Overall, 647 patients were eligible for this study. The incidence of postoperative complications was 28.1%, with postoperative pulmonary complications occurring in 24.7%. In multivariate analysis, anteroposterior thoracic diameter > 10.2 cm was an independent risk factor for postoperative complications (OR = 1.891, 95% CI: 1.137-3.146, p = 0.014), transverse thoracic diameter > 23.3 cm was an independent risk factor for postoperative pulmonary complications (OR = 2.243, 95% CI: 1.234-4.079, p = 0.004). In open group, transverse thoracic diameter over 23.3 cm correlated independently with postoperative complications (OR = 2.451, 95% CI: 1.219-4.927, p = 0.012) and postoperative pulmonary complications (OR = 2.988, 95% CI: 1.407-6.347, p = 0.004). However, this correction was not significant in laparoscopy-assisted group.

CONCLUSIONS

Thoracic size is an independent risk factor affecting the postoperative outcomes of transabdominal gastrectomy for Siewert type II and III AEG. Patients with larger thoracic cage are at a higher risk of postoperative complications, particularly pulmonary complications. For those patients, laparoscopic surgery may be a viable option.

Esophago-jejunal anastomosis with open approach using the parachute technique to prioritize safety after resection of esophagogastric junction cancer

BACKGROUND

The appropriate extent of resection for esophagogastric junction cancer and the method of surgical approach remain controversial. This study aimed to assess the safety and outcomes of the parachute technique, which is an open transhiatal reconstruction method that facilitates stable reconstruction.

MATERIALS AND METHODS

The surgical outcomes of 20 consecutive patients who underwent open lower- esophagogastrectomy for EGJ cancer at Kitasato University Hospital from June 2019 to July 2023 were retrospectively reviewed.

SURGICAL PROCEDURE (PARACHUTE TECHNIQUE)

The esophagus was transected, and a purse-string suture was placed at the stump. Then, a fixing string was placed. Hence, the mucosa, muscular layer, and adventitia, including the string of the purse-string suture, were not displaced. By placing approximately 10 stay sutures around the whole esophageal stump, the esophageal stump can be opened to the maximum diameter. Then, insert the anvil head into the esophagus lumen while laying it sideways, and it can be put on smoothly without stress.

RESULTS

In total, there were 17 and 3, male and female patients, respectively. The median esophageal invasion length was 12.5 (0-30) mm. One patient presented with cStage I EGJ cancer, four with cStage II, 14 with cStage III, and one with cStage IV. In terms of postoperative complications, three (15%) patients developed grade II intra-abdominal fluid correction according to the Clavien-Dindo classification. However, none of the patients presented with anastomotic leakage.

CONCLUSIONS

The parachute technique can be a safe and effective reconstruction technique as it does not cause anastomotic leakage.

Novel reconstruction using pedicled ileocolic interposition with intrathoracic esophago-ileal anastomosis after distal esophagectomy for esophagogastric junction cancer: A report of two cases

There is no optimal reconstruction after radical distal esophagectomy for cancers of the esophagogastric junction. We designed a novel reconstruction technique using pedicled ileocolic interposition with intrathoracic anastomosis between the esophagus and the elevated ileum. Two patients underwent the surgery. Case 1 was a 70-year-old man with esophagogastric junction adenocarcinoma with 3 cm of esophageal invasion. Case 2 was a 70-year-old man with squamous cell carcinoma of the esophagogastric junction; the epicenter of which was located just at the junction. These two patients underwent radical distal esophagectomy and pedicled ileocolic interposition with intrathoracic anastomosis. They were discharged on postoperative days 17 and 14, respectively, with no major complication. Pedicled ileocolic interposition is characterized by sufficient elevation and perfusion of the ileum, which is fed by the ileocolic artery and vein. As a result, we can generally adapt this reconstruction method to most curable esophagogastric junction cancers.

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

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 safe, highlighting its advantages for Siewert type II/III esophagogastric junction adenocarcinoma with an esophageal invasion length of ≤ 4 cm.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

INTRODUCTION

To date, the discussion is still ongoing whether the Siewert II adenocarcinoma of the esophagogastric junction (AEG) should be resected either by thoracoabdominal esophagectomy or gastrectomy with resection of the distal esophagus by transhiatal extension. The aim of our study was to compare the oncological and perioperative outcomes of the transthoracic approach (TTA) and the transabdominal approach (TAA).

METHODS

Searches of electronic databases identifying studies from Cochrane, PubMed and Google Scholar were performed. Randomised and non-randomised studies comparing TTA and TAA approaches for surgical treatment of AEG Siewert type II were included. The Newcastle-Ottawa and Jada scales were used to evaluate methodological quality. The risk of bias was assessed using the Rob v2 and Robins-I tools. Meta-analyses were conducted for the outcomes.

RESULTS

We included 17 trials (2 randomised controlled trials and 15 cohorts) involving 15297 patients. Longer three-year overall survival, five-year overall survival and R0 resection rates were observed in the TTA group. However, TTA had greater morbidity and pulmonary complications.

CONCLUSION

Transthoracic approach appears to be preferable for selected Siewert II tumours. This may lead to higher survival rates and better R0 resection rate. Well-designed studies are needed to confirm the results of this systematic review.

Comparison of Short-Term Outcomes After Robotic Versus Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer in Elderly Individuals: A Propensity Score-Matching Study

BACKGROUND

Robotic gastrectomy (RG) has been widely used to treat gastric cancer. However, whether the short-term outcomes of robotic gastrectomy are superior to those of laparoscopic gastrectomy (LG) for elderly patients with advanced gastric cancer has not been reported.

METHODS

The study enrolled of 594 elderly patients with advanced gastric cancer who underwent robotic or laparoscopic radical gastrectomy. The RG cohort was matched 1:3 with the LG cohort using propensity score-matching (PSM).

RESULTS

After PSM, 121 patients were included in the robot group and 363 patients in the laparoscopic group. Excluding the docking and undocking times, the operation time of the two groups was similar (P = 0.617). The RG group had less intraoperative blood loss than the LG group (P < 0.001). The time to ambulation and first liquid food intake was significantly shorter in the RG group than in the LG group (P < 0.05). The incidence of postoperative complications did not differ significantly between the two groups (P = 0.14). Significantly more lymph nodes were dissected in the RG group than in the LG group (P = 0.001). Postoperative adjuvant chemotherapy was started earlier in the RG group than in the LG group (P = 0.02).

CONCLUSIONS

For elderly patients with advanced gastric cancer, RG is safe and feasible. Compared with LG, RG is associated with less intraoperative blood loss; a faster postoperative recovery time, allowing a greater number of lymph nodes to be dissected; and earlier adjuvant chemotherapy.

Preoperative ultrasound-guided dual localization with titanium clips and carbon nanoparticles for predicting the surgical approach and guiding the resection of Siewert type II esophagogastric junction adenocarcinoma

OBJECTIVE

To investigate the superiority of preoperative ultrasound-guided titanium clip and nanocarbon dual localization over traditional methods for determining the surgical approach and guiding resection of Siewert type II adenocarcinoma of the esophagogastric junction (AEG).

METHOD

This study included 66 patients with Siewert type II AEG who were treated at the PLA Joint Logistics Support Force 900th Hospital between September 1, 2021, and September 1, 2023. They were randomly divided into an experimental group (n = 33), in which resection was guided by the dual localization technique, and the routine group (n = 33), in which the localization technique was not used. Surgical approach predictions, proximal esophageal resection lengths, pathological features, and the occurrence of complications were compared between the groups.

RESULT

The use of the dual localization technique resulted in higher accuracy in predicting the surgical approach (96.8% vs. 75.9%, P = 0.02) and shorter proximal esophageal resection lengths (2.39 ± 0.28 cm vs. 2.86 ± 0.39 cm, P < 0.001) in the experimental group as compared to the routine group, while there was no significant difference in the incidence of postoperative complications (22.59% vs. 24.14%, P = 0.88).

CONCLUSION

Preoperative dual localization with titanium clips and carbon nanoparticles is significantly superior to traditional methods and can reliably delineate the actual infiltration boundaries of Siewert type II AEG, guide the surgical approach, and avoid excessive esophageal resection.

A Novel Method for Thoracoscopic Overlap Esophagogastric Reconstruction With Pleural Closure following Minimally Invasive Ivor-Lewis Esophagectomy for Esophagogastric Junction Cancer

BACKGROUND

Intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy is a technically demanding surgical technique that can result in serious intrathoracic infections when anastomotic leakage occurs. Herein, we report a novel side-overlap esophagogastric anastomosis with pleural closure for esophagogastric junction cancer.

METHODS

The 3 key points of our novel technique were the following: (1) overlap esophagogastric anastomosis and closure of the entry hole were all performed using a linear stapler; (2) the pleura was closed to separate the anastomotic site from the thoracic cavity; and (3) the mediastinal drain was inserted transhiatally from the abdominal cavity.

RESULTS

This modified anastomosis procedure was performed on 8 consecutive patients at our institution. The median overall/thoracoscopic operating time and estimated blood loss were 652.5/241.5 min and 89 mL, respectively. No mortality or serious postoperative complications occurred, and the median postoperative hospital stay was 22 days (range, 17 to 37 d).

CONCLUSION

This novel thoracoscopic overlap esophagogastric reconstruction procedure with pleural closure is safe and feasible.

Surgical and Perioperative Treatments for Esophagogastric Junction Cancer

Esophagogastric junction cancer (EGJC) is a rare malignant disease that occurs in the gastroesophageal transition zone. In recent years, its incidence has been rapidly increasing not only in Western countries but also in East Asia, and it has been attracting the attention of both clinicians and researchers. EGJC has a worse prognosis than gastric cancer (GC) and is characterized by complex lymphatic drainage pathways in the mediastinal and abdominal regions. EGJC was previously treated in the same way as GC or esophageal cancer, but, in recent years, it has been treated as an independent malignant disease, and treatment focusing only on EGJC has been developed. A recent multicenter prospective study revealed the frequency of lymph node metastasis by station and established the optimal extent of lymph node dissection. In perioperative treatment, the combination of multi-drug chemotherapy, radiation therapy, molecular targeted therapy, and immunotherapy is expected to improve the prognosis. In this review, we summarize previous clinical trials and their important evidence on surgical and perioperative treatments for EGJC.

Impact of the Surgical Approach for Neoadjuvantly Treated Gastroesophageal Junction Type II Tumors: A Multinational, High-volume Center Retrospective Cohort Analysis

OBJECTIVE

The aim of this study was to explore oncologic outcomes of transhiatal gastrectomy (THG) or transthoracic esophagectomy (TTE) for neoadjuvantly treated gastroesophageal junction (GEJ) Siewert type II adenocarcinomas, a multinational, high-volume center cohort analysis was undertaken.

BACKGROUND

Neoadjuvant radiochemotherapy or perioperative chemotherapy (CTx) followed by surgery is the standard therapy for locally advanced GEJ. However, the optimal surgical approach for type II GEJ tumors remains unclear, as the decision is mainly based on individual experience and assessment of operative risk.

METHODS

A retrospective analysis of 5 prospectively maintained databases was conducted. Between 2012 and 2021, 800 patients fulfilled inclusion criteria for type II GEJ tumors and neoadjuvant radiochemotherapy or CTx. The primary endpoint was median overall survival (mOS). Propensity score matching was performed to minimize selection bias.

RESULTS

Patients undergoing THG (n=163, 20.4%) had higher American Society of Anesthesiologists (ASA) classification and cT stage ( P <0.001) than patients undergoing TTE (n=637, 79.6%). Neoadjuvant therapy was different as the THG group were mainly undergoing CTx (87.1%, P <0.001). The TTE group showed higher tumor regression ( P =0.009), lower ypT/ypM categories (both P <0.001), higher nodal yield ( P =0.009) and higher R0 resection rate ( P =0.001). The mOS after TTE was longer (78.0 vs 40.0 months, P =0.013). After propensity score matching a higher R0 resection rate ( P =0.004) and mOS benefit after TTE remained ( P =0.04). Subgroup analyses of patients without distant metastasis ( P =0.037) and patients only after neoadjuvant chemotherapy ( P =0.021) confirmed the survival benefit of TTE. TTE was an independent predictor of longer survival.

CONCLUSION

Awaiting results of the randomized CARDIA trial, TTE should in high-volume centers be considered the preferred approach due to favorable oncologic outcomes.

Essential updates 2021/2022: Perioperative and surgical treatments for gastric and esophagogastric junction cancer

In recent years, important clinical trials for gastric cancer (GC) and esophagogastric junction cancer (EGJC) have been reported, changing the strategies of surgical and perioperative treatment. Although laparoscopic gastrectomy has already been shown to be effective for early-stage cancer, recent evidence from both Asia (JLSSG0901, CLASS-01 and KLASS-02) and Europe (LOGICA and STOMACH trials) has demonstrated that it is useful for advanced GC. Robotic surgery has been rapidly gaining popularity in recent years, and randomized controlled trials are ongoing to evaluate its efficacy. A prospective nationwide multicenter study mapped sites with frequent metastasis and revealed lymphatic flow specific to EGJC, thus establishing the optimal lymph node dissection area and surgical approach based on esophageal involvement. Perioperative chemotherapy, the mainstay of treatment in Europe, also has been established in Asia by the PRODIGY and RESOLVE studies. New clinical trials have been conducted to evaluate the efficacy of combining immunotherapy or molecular-targeted therapy with perioperative chemotherapy or chemoradiotherapy. In this review, we present important recent clinical trials regarding the treatment of GC and EGJC published in 2021 or 2022.

Analysis of surgical outcomes and risk factors for anastomotic leakage following trans-hiatal resection of esophagogastric junction cancer

BACKGROUND

The trans-hiatal lower esophagectomy is considered less invasive than the trans-thoracic esophagectomy for resection of esophagogastric junction (EGJ) cancer. However, the optimal procedure remains controversial and should be determined while considering both oncological and safety aspects.

METHODS

This retrospective study comprised 124 patients that underwent curative resection for EGJ cancer. The study analysis included 93 patients with tumor centers located within 2 cm of the EGJ. Clinicopathological findings and surgical outcomes were compared between patients treated using trans-hiatal and trans-thoracic approaches.

RESULTS

Sixty-three patients underwent lower esophagectomy using the trans-hiatal approach (TH-G). The remaining 30 patients underwent esophagectomy using the trans-thoracic approach (TT-E). The TH-G group were older, had a lower prevalence of lymphatic spread, shorter length of esophageal invasion, and shorter operative duration compared to the TT-E group. Although no significant differences in the frequency of postoperative complications, a higher proportion of patients in the TH-G group developed anastomotic leakage (16% vs. 7%, p = 0.33). Univariate and multivariate analyses demonstrated that cardiac comorbidity was an independent risk factor for anastomotic leakage (odds ratio, 5.24; 95% CI, 1.06-25.9; P < 0.05) in TH-G group. Further examination revealed that preoperative cardiothoracic ratio (CTR) with 50% or greater could be surrogate marker as risk factor for anastomotic leakage in TH-G group (35% vs. 7.5%, p < 0.05).

CONCLUSIONS

The trans-hiatal approach can be used for resection of EGJ cancer. However, special attention should be paid to the prevention of anastomotic leakage in patients with cardiac comorbidities or a large preoperative CTR.

Clinical Impact of Positive Surgical Margins in Gastric Adenocarcinoma in the Era of Preoperative Therapy

BACKGROUND

Microscopically positive (R1) surgical margins after gastrectomy increase gastric cancer recurrence risk, but optimal management after R1 gastrectomy is controversial. We sought to identify the impact of R1 margins on recurrence patterns and survival in the era of preoperative therapy for gastric cancer.

METHODS

Patients who underwent gastrectomy for adenocarcinoma during 1998-2017 at a major cancer center were enrolled. Clinicopathologic factors associated with positive margins were examined, and incidence, sites, and timing of recurrence and survival outcomes were compared between patients with positive and negative margins.

RESULTS

Of 688 patients, 432 (63%) received preoperative therapy. Thirty-four patients (5%) had R1 margins. Compared with patients with negative margins, patients with R1 margins more frequently had aggressive clinicopathologic features, such as linitis plastica (odds ratio [OR] 7.79, p < 0.001) and failure to achieve cT downstaging with preoperative treatment (OR 5.20, p = 0.005). The 5 year overall survival (OS) rate was lower in patients with R1 margins (6% vs 60%; p < 0.001), and R1 margins independently predicted worse OS (hazard ratio 2.37, 95% CI 1.51-3.75, p < 0.001). Most patients with R1 margins (58%) experienced peritoneal recurrence, and locoregional recurrence was relatively rare in this group (14%). Median time to recurrence was 8.5 months for peritoneal dissemination and 15.7 months for locoregional recurrence.

CONCLUSION

R1 margins after gastrectomy were associated with aggressive tumor biology, high incidence of peritoneal recurrence after a short interval, and poor OS. In patients with R1 margins, re-resection to achieve microscopically negative margins has to be considered with caution.

Prognostic nomograms for gastric carcinoma after D2 + total gastrectomy to assist decision-making for postoperative treatment: based on Lasso regression

OBJECTIVE

This study aimed to establish novel nomograms that could be used to predict the prognosis of gastric carcinoma patients who underwent D2 + total gastrectomy on overall survival (OS) and progression-free survival (PFS).

METHODS

Lasso regression was employed to construct the nomograms. The internal validation process included bootstrapping, which was used to test the accuracy of the predictions. The calibration curve was then used to demonstrate the accuracy and consistency of the predictions. In addition, the Harrell's Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate the discriminative abilities of the new nomograms and to compare its performance with the 8th edition of AJCC-TNM staging. Furthermore, decision curve analysis (DCA) was performed to assess the clinical application of our model. Finally, the prognostic risk stratification of gastric cancer was conducted with X-tile software, and the nomograms were converted into a risk-stratifying prognosis model.

RESULTS

LASSO regression analysis identified pT stage, the number of positive lymph nodes, vascular invasion, neural invasion, the maximum diameter of tumor, the Clavien-Dindo classification for complication, and Ki67 as independent risk factors for OS and pT stage, the number of positive lymph nodes, neural invasion, and the maximum diameter of tumor for PFS. The C-index of OS nomogram was 0.719 (95% CI: 0.690-0.748), which was superior to the 8th edition of AJCC-TNM staging (0.704, 95%CI: 0.623-0.783). The C-index of PFS nomogram was 0.694 (95% CI: 0.654-0.713), which was also better than that of the 8th edition of AJCC-TNM staging (0.685, 95% CI: 0.635-0.751). The calibration curves, t-ROC curves, and DCA of the two nomogram models showed that the prediction ability of the two nomogram models was outstanding. The statistical difference in the prognosis between the low- and high-risk groups further suggested that our model had an excellent risk stratification performance.

CONCLUSION

We reported the first risk stratification and nomogram for gastric carcinoma patients with total gastrectomy in Chinese population. Our model could potentially be used to guide treatment selections for the low- and high-risk patients to avoid delayed treatment or unnecessary overtreatment.

Current status and future perspectives for the treatment of resectable locally advanced esophagogastric junction cancer: A narrative review

Incidence rates for esophagogastric junction cancer are rising rapidly worldwide possibly due to the economic development and demographic changes. Therefore, increased attention has been paid to the prevention, diagnosis, and the treatment of esophagogastric junction cancer. Although there are discrepancies in the treatment strategy between Asian and Western countries, surgery remains the mainstay of treatment for esophagogastric junction cancer. Recent developments of perioperative multidisciplinary treatment may lead to better therapeutic effect, higher complete resection rate, and better control of the residual diseases, thus result in prolonged prognosis. In this review, we will focus on the treatment of locally advanced resectable esophagogastric junction cancer, and discuss the current status and future perspectives of the perioperative treatment including chemotherapy, radiation therapy, and immunotherapy, as well as the surgical strategy. Better understanding of the latest treatment strategy and future overlook may enable to standardize and individualize the treatment for esophagogastric junction cancer, thus leading to better prognosis for those patients.

Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis

BACKGROUND

Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis.

METHODS

A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher.

RESULTS

The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011).

CONCLUSIONS

There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm.

Surgical Treatment of Siewert II Gastroesophagel Junction Adenocarcinoma: Esophagectomy or Gastrectomy? Review

Introduction. Surgery is the only curative treatment option for patients with gastroesophageal junction (GEJ) adenocarcinoma. These tumors can be resected by gastrectomy or esophagectomy depending on tumor localization. Although, both surgeries are available for Siewert type II GEJ cancer, it remains unknown which one is superior. This review summarizes current evidences on the optimal surgical approach for Siewert type II GEJ adenocarcinoma. Methods. The literature search was performed within the PubMed database and 9 stu­dies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma were included. The outcomes of interest included: length of surgery, numbers of retrieved lymph nodes, resection margins, postoperative morbidity and mortality, hospitalization time, 5-year overall, and disease-free survival rates. Results. Current studies do not favor any type of surgery in terms of length of the surgery, R0 resection rate, or postoperative morbidity. There is some tendency towards higher anastomotic leakage and postoperative surgical site infections rate after gastrectomy, while a higher incidence of pneumonia after esophagectomy. Similar, available studies suggest, that esophagectomy may lead to improved long-term outcomes. Conclusions. There is a lack of high-quality studies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma. Esophagectomy may lead to improved long-term outcomes, but this preliminary data has to be confirmed in large, randomized control trials.

Whether the infracardiac bursa protect right pleura during laparoscopic radical operation of Siewert type II adenocarcinoma of esophagogastric junction?

BACKGROUND

Transthoracic single-port assisted laparoscopic five-step maneuver inferior mediastinal lymphadenectomy for Siewert type II adenocarcinoma of esophagogastric junction (AEG) has superiority in lower mediastinal lymph nodes dissection and digestive tract reconstruction. However, the right pleura was probably ruptured in this surgical technique. The aim of this study was to explore whether the infracardiac bursa (ICB) exposed could protect right pleura.

METHODS

We retrospectively collected and evaluated the clinical and pathological data of patients who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymphadenectomy for Siewert II AEG at Guangdong Provincial Hospital of Chinese Medicine between May 2017 and February 2022.

RESULTS

A total of 49 patients were eligible, including 31 patients in ICB exposed group (group A) and 18 patients in ICB unexposed group (group B). There were no statistically significant differences in baseline characteristics between the two groups. 4 patients (12.9%) had right pleura rupture in group A, while 14 patients (77.8%) in group B, and the difference was statistically significant (p < 0.001). Compared with group B, the extubation time of endotracheal intubation (10.0 (6.0 ~ 12.0) vs. 13.0 (8.0 ~ 15.0) min, p = 0.003) and thoracic drainage tube stay (6.0 (5.0 ~ 7.0) vs. 8.0 (6.0 ~ 10.5) days, p = 0.041) were significantly shorted in the group A. The drainage volume of thorax (351.61 ± 125.00 vs. 418.61 ± 207.86 mL, p = 0.146) was non-significant less and the rate of complications (3.2% vs. 11.1%, p = 0.074) was non-significant lower in group A compared with group B. The postoperative hospital stay (9.0 (8.0,13.0) vs. 9.0 (8.0,12.0) days, p = 0.983) were similar in two groups. No serious adverse event occurred in any patient.

CONCLUSIONS

The ICB exposed could protect the right pleura and may promote postoperative recovery, which may be used as an anatomical marker in inferior mediastinal lymphadenectomy.

Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction

PURPOSE

Despite the increasing incidence of adenocarcinoma of the esophagogastric junction, laparoscopic proximal gastrectomy with lower esophagectomy (PGLE) is not widely accepted owing to the lack of standardized reconstruction techniques. In this study, we developed a new reconstruction method named y-shaped overlap esophagogastric tube reconstruction, which reproduces an angle of His and a pseudo-fornix, to be used in laparoscopic transhiatal PGLE. This study aimed to determine the feasibility of this novel reconstruction method.

METHODS

This retrospective study included the analysis of short- and mid-term surgical outcomes of 30 consecutive patients with Siewert type II esophagogastric junction adenocarcinoma who underwent laparoscopic PGLE with y-shaped overlap esophagogastric tube reconstruction from April 2015 to August 2020. A novel method was used to form a 6-cm pseudo-fornix and an angle of His using the distal esophagus and a long gastric tube.

RESULTS

The median operation time was 369 min, and the median blood loss was 28 mL. The median follow-up period after surgery was 37 months. Although two patients experienced postoperative anastomotic leakage, none of the patients developed stenosis. One patient experienced moderate reflux symptoms, whereas four patients developed moderate reflux esophagitis based on the 1-year follow-up endoscopic examination; the condition of all patients could be efficiently controlled with medication.

CONCLUSION

The short- and mid-term surgical outcomes of y-shaped overlap esophagogastric tube reconstruction reflected the feasibility of this simple technique and suggested its potential utility as a reconstruction alternative for Siewert type II tumors.