What Is the Best Operation for Proximal Gastric Cancer and Distal Esophageal Cancer?

Neoadjuvant Treatment Strategies for Resectable Proximal Gastric, Gastroesophageal Junction and Distal Esophageal Cancer

Simple Summary

The five-year survival for resectable proximal gastric, gastroesophageal junction (GEJ), and distal esophageal cancer ranges from 30 to 60% globally. Neoadjuvant and/or perioperative therapy has emerged as a treatment tool to improve patient selection for surgery, resectability, and locoregional control of the disease. As a result, treatment strategies have evolved from the first trials in the late 1980s to the pivotal CROSS trial updated in 2015. The review summarizes current clinical trials and treatment recommendations with regard to neoadjuvant and/or perioperative therapy for patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus, GEJ, and proximal stomach.

Abstract

Neoadjuvant treatment strategies for resectable proximal gastric, gastroesophageal junction (GEJ), and distal esophageal cancer have evolved over several decades. Treatment recommendations differ based on histologic type—squamous cell carcinoma (SCC) versus adenocarcinoma (AC)—as well as the exact location of the tumor. Recent and older clinical trials in this area were critically reviewed. Neoadjuvant chemoradiation with concurrent taxane- or fluoropyrimidine-based chemotherapy has an established role for both AC and SCC of the distal esophagus and GEJ. The use of perioperative chemotherapy for gastric AC is based on the FLOT4 and MAGIC trials; however, the utility of neoadjuvant chemoradiation in this setting requires further evaluation. Additional clinical trials evaluating chemotherapy, targeted therapy, immunotherapy, and radiation that are currently in process are highlighted, given the need for further disease control.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 2): UPDATE ON TREATMENT

BACKGROUND

: The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented.

AIM

: To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment.

METHODS

To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation.

RESULTS

: Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3.

CONCLUSION

: The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

Advances in the surgical management of gastric and gastroesophageal junction cancer

Since Theodore Billroth and Cesar Roux perfected the methods of post-gastrectomy reconstruction in the late 19^th century, surgical management of gastric and gastroesophageal cancer has made incremental progress. The majority of patients with localized disease are treated with perioperative combination chemotherapy or neoadjuvant chemoradiation. Staging laparoscopy before initiation of treatment or before surgical resection has improved staging accuracy and can drastically inform treatment decisions. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer appears to have settled in favor of D2 dissection with the recently published 15-year follow-up of the Dutch randomized trial. Minimally invasive gastric and gastroesophageal resections are performed routinely in most centers affording faster recovery and equivalent oncologic outcomes. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers, while randomized data on its oncologic adequacy are pending. Multi-visceral resections and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has been utilized selectively for patients with locally advanced tumors who have demonstrated disease control on preoperative chemotherapy. This review summarizes the current standard of surgical care for gastroesophageal junction and gastric cancer as well as highlights recent and upcoming advances to the field.

Transhiatal versus transthoracic surgical approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

With the increasing prevalence of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (EGJ), the optimal surgical treatment is not universally agreed. This meta-analysis compares the safety and efficacy between the transhiahtal (TH) approach and the transthoracic (TT) approach.

METHODS

A systematic and electronic search of several databases was performed up to June 2020. The Newcastle-Ottawa scale was used to evaluate article quality and funnel plots were created to identify potential publication bias. The random-effects model was used when significant heterogeneity was identified.

RESULTS

In total, nine retrospective studies and two randomized controlled trials (RCTs) involving 2331 patients were included. Decreased intraoperative blood loss, shorter hospital stay, lower incidence of pulmonary complications, and longer 3-year overall survival were observed in the TH group. There were no significant differences concerning duration of surgery, R0 resection rate, number of dissected lymph nodes, perioperative mortality and morbidity rate, abdominal complication rate, or anastomotic leak rate. With regard to 5-year overall survival, a potential benefit may be achieved with the TH approach, which requires further confirmation.

CONCLUSION

In terms of surgery-related and long-term outcomes, the TH approach may be more appropriate for Siewert type Ⅱ adenocarcinoma of EGJ, especially for esophagus invasion ≤4 cm.

Treatment Alternatives for Recurrent Esophagogastric Junction Adenocarcinoma: Case Report of an Ileocolonic Reconstruction and Literature Review

Esophagogastric junction tumors are a challenging pathology for surgeons and the best treatment depends on an adequate initial localization and stadification. Approximately half of patients relapse after curative surgery during the first two years. Surgical resection could increase the survival of these patients, but the esophageal reconstruction is a surgical challenge for which there are multiple reconstruction techniques described with different organs. In this report, we present the case of a patient with an esophagogastric junction tumor treated initially with total gastrectomy and esophageal margin. The patient presented an anastomotic recurrence that was taken to surgical resection, but a second recurrence required a residual esophagectomy with ileocolonic reconstruction, to achieve adequate oncologic treatment.

Predominant classic circular-stapled double-tract reconstruction after totally laparoscopic proximal gastrectomy: safe, feasible, time-saving anastomoses by technical tie-up

BACKGROUND

The double-tract reconstruction (DTR) could be a preferable option in avoiding the postoperative esophageal reflux and anastomotic stenosis during totally laparoscopic proximal gastrectomy (TLPG). An optimal procedure to achieve the DTR in TLPG remains to be established.

METHODS

During March 2018 to April 2019, 15 consecutive patients with gastric cancer in the upper third of the stomach underwent intracorporeal DTR after TLPG at our hospital. The intracorporeal esophagojejunostomy (E-J), gastrojejunostomy (G-J) and jejunojejunostomy (J-J) were, respectively, performed using circular staplers by the Self-Pulling and Holding Purse-String Suture Technique, Intraluminal Poke Technique and U-shaped Parallel Purse-string Suture Technique (Technical Tie-Up). Demographic and clinicopathologic characteristics, perioperative details and postoperative outcomes were analyzed.

RESULTS

The mean operating time was 216.1 ± 18.2 min. Total time for three anastomoses was 49.8 ± 6.1 min, and the time for E-J, G-J, J-J was 22.4 ± 5.0 min, 13 (range 11-16) min, 14.2 ± 2.8 min, respectively. The median proximal and distal resection margins were 2.5 (range 2-4) cm and 6 (range 5-7) cm, respectively, which were all tumor-free in 15 patients. No major complications and mortality occurred. During the median follow-up period of 14 months (range 7 to 20.5 months), there were no postoperative anastomosis-related complications observed, such as anastomotic bleeding, leakage or stenosis. No patients complained the symptoms indicating esophageal reflux and remnant gastritis.

CONCLUSIONS

Predominant classic circular-stapled double-tract reconstruction is safe, feasible and time-saving in TLPG by the technical tie-up.