Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia

Effect of different surgical approaches on the survival and safety of Siewert type II esophagogastric junction adenocarcinoma: a systematic review and meta-analysis

BACKGROUND

Whether a transthoracic (TT) procedure by a thoracic surgeon or a transabdominal (TA) by a gastrointestinal surgeon is best for Siewert type II esophagogastric junction adenocarcinoma (EGJA) remains unknown. Survival and perioperative outcomes were compared between the two groups in this meta-analysis to clarify this argument.

METHODS

We searched 7 databases for eligible studies comparing TT and TA procedures for Siewert type II EGJA. The final analyzed endpoints included intraoperative and hospitalization outcomes, recurrence, complication, and survival.

RESULTS

Seventeen studies involving 10,756 patients met the inclusion criteria. The TA group had higher rates of overall survival (OS) (HR: 1.31 [1.20 ~ 1.44], p < 0.00001) and disease-free survival (DFS) (HR: 1.49 [1.24 ~ 1.79], p < 0.0001). The survival advantage of OSR and DFSR increased with time. Subgroup analysis of OS and DFS suggested that TA remained the preferred approach among all subgroups. More total/positive lymph nodes were retrieved, and fewer lymph node recurrences were found in the TA group. The analysis of perioperative outcomes revealed that the TA procedure was longer, had more intraoperative blood loss, and prolonged hospital stay. Similar R0 resection rates, as well as total recurrence, local recurrence, liver recurrence, peritoneal recurrence, lung recurrence, anastomosis recurrence and multiple recurrence rates, were found between the two groups. The safety analysis showed that the TT procedure led to more total complications, anastomotic leakages, cases of pneumonia, and cases of pleural effusion.

CONCLUSIONS

The TA procedure appeared to be a suitable choice for patients with Siewert type II EGJA because of its association with longer survival, fewer recurrences, and better safety.

Secure Robotic Transthoracic Valvuloplastic Esophagogastrostomy by Double Flap Technique in Esophagogastric Junctional Cancer Surgery

Valvuloplastic esophagogastrostomy by the double flap technique (VPEG-DFT) after proximal gastrectomy for early proximal gastric cancer or esophagogastric junctional cancer (EGJC) is a promising procedure to prevent reflux. However, the transhiatal procedure alone for alimentary reconstruction is sometimes too complex because of the short esophageal remnant. Therefore, additional transthoracic procedures are needed in some patients with EGJC. Although additional thoracoscopic surgery has been reported, no reports to date have described robotic transthoracic VPEG-DFT after excision of EGJC. We herein describe the secure robotic techniques of transthoracic VPEG-DFT performed in 3 patients with EGJC. After completion of the abdominal procedures by robotic and extracorporeal creation of H -shaped flaps on the gastric remnant, robotic VPEG-DFT through the right thoracic approach was performed in the prone position. To accomplish VPEG-DFT in the thorax of patients in the prone position, fixation of the esophagus and stomach was performed before the rotation of the 2 organs to expose the planned anastomotic aspect. In addition, the final abdominal phase was required again to prevent a postoperative hiatal hernia. Secure techniques of right transthoracic VPEG-DFT by robotic surgery could contribute to the successful treatment of EGJC when the remnant esophagus is too short.

Comparison of Efficacy Between Transabdominal and Transthoracic Surgical Approaches for Siewert Type II Adenocarcinoma of the Esophagogastric Junction: A Systematic Review and Meta-Analysis

Background

The optimal surgical approach, whether transabdominal (TA) or transthoracic (TT), for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) remains controversial. This study compares the efficacy of TA and TT surgical approaches for Siewert type II AEG.

Methods

Studies comparing the surgical and oncological outcomes of TA and TT surgical approaches for Siewert type II AEG up to June 2021 were systematically searched on the Web of Science, PubMed, Embase, and Cochrane Library. A pooled analysis was performed for the available data regarding the baseline features, surgical, and oncological outcomes. The RevMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.

Results

Twelve studies with a total of 2,011 patients, including 985 patients in the TA group and 1,026 patients in the TT group, were included in this study. In the pooled analysis, the surgical outcomes, namely, operative time (MD = −54.61, 95% CI = −123.76 to 14.54, P = 0.12), intraoperative blood loss (MD = −28.85, 95% CI = −71.15 to 13.46, P = 0.18), the number of dissected lymph nodes (MD = 1.90, 95% CI = −1.32 to 5.12, P = 0.25), postoperative complications (OR = 0.84, 95% CI = 0.65 to 1.07, p = 0.16), anastomotic leakage rate (OR = 1.02, 95% CI = 0.63 to 1.65, p = 0.93), and postoperative death rate (OR = 0.89, 95% CI = 0.46 to 1.72, p = 0.73), and the oncological outcomes, namely, overall recurrence rate (OR = 0.75, 95% CI = 0.37 to 1.50, p = 0.41), 3-year overall survival (OS) rate (OR = 1.19, 95% CI = 0.54 to 2.65, p = 0.66), and 5-year OS rate (OR = 1.21, 95% CI = 0.84 to 1.74, p = 0.30) of the two groups were all comparable.

Conclusions

Both TA and TT surgical approaches are appropriate for Siewert type II AEG, and neither has a significant advantage in terms of short- and long-term outcomes. However, more high-quality randomized controlled trials are needed to confirm this conclusion.

For Gastroesophageal Junction Cancers, Does an "Esophageal" or "Gastric" Surgical Approach Offer Better Perioperative and Oncologic Outcomes?

BACKGROUND

The optimal surgical approach to the resection of gastoesophageal junction cancer is unknown. A comprehensive literature search was conducted to further compare the esophageal and gastric approaches to gastroesophageal junction cancer.

METHODS

A systematic review of the literature from January 1990 to May 2018 was performed to determine whether an esophageal or gastric surgical approach offers better perioperative and oncologic outcomes.

RESULTS

A total of 179 abstracts were identified and after excluding publications for non-English language, primary focus on neoadjuvant and/or adjuvant treatment, lack of comparison of surgical approaches or not addressing morbidity, mortality, or survival-related outcomes, a total of 14 nonrandomized, comparative studies were reviewed in detail.

CONCLUSIONS

The proximal and distant extent of the tumor based on Siewert type classification greatly influences choice of operation. Overall survival rates and surgical outcomes are comparable, and surgical approach should be dictated by patient factors.

Meta-analysis of Transhiatal Esophagectomy in carcinoma of esophagogastric junction, does it have an advantage?

PURPOSE

Compare the clinical outcome of Transhiatal Esophagectomy (THE) approach and open Thoracic Esophagectomy (TTE) approach in the carcinoma of esophagogastric junction (CEGJ).

METHODS

Relevant literature published until 2016 from PubMed, Cochrane Library, Ovid (Medline) and EMBASE were retrieved. Meta-analysis was achieved by using the Stata12 software.

RESULTS

A total of 18 studies and 2202 cases of patients were involved in this meta-analysis. THE showed to decrease the hospital stay, hospital mortality, surgical time, and blood loss in the operation. However, fewer lymph nodes would be yielded by this surgical option. A 5-year survival advantage of THE was only observed in North America subgroup.

CONCLUSIONS

Except the above operative related advantages, there was no clear evidence that THE has a further advantage in CEGJ.

Outcome of Surgery for Oesophageal Carcinoma in a Low Volume Centre, with and without Preoperative Chemoradiotherapy

Aims:

To critically assess the outcome of surgery for oesophageal carcinoma, with or without neoadjuvant chemoradiotherapy.

Methods:

Since April 1998 until August 2002 resectable oesophageal cancer patients referred to us have received multimodal treatment, consisting of two courses of fluorouracil, cisplatin and hydroxyurea and 20 Gy of radiotherapy followed by surgery. The outcome of this treatment was compared to the outcome of a historical group of oesophageal cancer patients, treated with surgery alone in the time period 1994 to 1998. The patients represent a consecutive series of 20 resectable oesophageal carcinomas, referred to us since 1994. Four patients (20 %) were treated for squamocellular carcinoma, 16 (80 %) patients for adenocarcinoma.

Results:

Treatment related toxicity was low and there was no death attributable to the chemoradiotherapy. Postoperative hospital mortality (< 30 days) and morbidity rates were 10 % and 50 %, respectively. A complete pathological response (T0) occurred in two of the nine patients in the multimodal group (22 %). Overall median survival was 11 months. Median survival among patients in the multimodal group was 14 months, as compared with 7 months in the group treated with surgery alone (P = 0.041).

Conclusions:

Despite low volume, outcome of surgery for oesophageal carcinoma was acceptable.

Transthoracic vs transhiatal surgery for cancer of the esophagogastric junction: A meta-analysis

AIM: To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction.

METHODS: An electronic and manual search of the literature was conducted in PubMed, EmBase and the Cochrane Library for articles published between March 1998 and January 2013. The pooled data included the following parameters: duration of surgical time, blood loss, dissected lymph nodes, hospital stay time, anastomotic leakage, pulmonary complications, cardiovascular complications, 30-d hospital mortality, and long-term survival. Sensitivity analysis was performed by excluding single studies.

RESULTS: Eight studies including 1155 patients with cancer of the esophagogastric junction, with 639 patients in the transthoracic group and 516 in the transhiatal group, were pooled for this study. There were no significant differences between two groups concerning surgical time, blood loss, anastomotic leakage, or cardiovascular complications. Dissected lymph nodes also showed no significant differences between two groups in randomized controlled trials (RCTs) and non-RCTs. However, we did observe a shorter hospital stay (WMD = 1.92, 95%CI: 1.63-2.22, P < 0.00001), lower 30-d hospital mortality (OR = 3.21, 95%CI: 1.13-9.12, P = 0.03), and decreased pulmonary complications (OR = 2.95, 95%CI: 1.95-4.45, P < 0.00001) in the transhiatal group. For overall survival, a potential survival benefit was achieved for type III tumors with the transhiatal approach.

CONCLUSION: The transhiatal approach for cancers of the esophagogastric junction, especially types III, should be recommended, and its long-term outcome benefits should be further evaluated.

Long-term outcomes of extended proximal gastrectomy for oesophagogastric junctional tumours

BACKGROUND

There is no consensus on the optimum approach for resection of oesophagogastric junctional (OGJ) tumours. We prospectively evaluated the efficacy of transabdominal radical extended proximal gastrectomy with oesophagogastric anastomosis (EPGOG) for selected tumours of the OGJ.

METHODS

Between 1998 and 2007, 66 selected consecutive patients with tumours of the OGJ underwent successful EPGOG. Selection was limited to tumours where the maximal proximal extent was 36 cm ab oral. Pre-, peri-, and postoperative outcomes together with long-term survival data for these patients were prospectively collected.

RESULTS

Median theatre time was 242 min (range = 120-480), with a median blood loss of 300 ml (range = 50-1720). Eighty-nine percent of patients were extubated in theatre; major complications occurred in 9 (14%) patients, with an overall in-hospital mortality rate of 8%. Thirty-five (53%) patients had nodal disease and the median lymph node yield was 13 (range = 4-36), with an R0 resection rate of 80%. In terms of long-term outcomes, the 2- and 5-year actuarial survival rates were 54 ± 6% and 41 ± 6%.

CONCLUSION

Extended radical proximal gastrectomy with oesophagogastric anastomosis for selected junctional tumours is a feasible technique which does not compromise oncological principles as evidenced by an excellent long-term survival rate.

Esophageal extension encountered during transhiatal resection of gastric or gastroesophageal tumors: attaining a negative margin

INTRODUCTION

Over the last several decades, the incidence of gastroesophageal junction tumors has been increasing. Often, patients present late in the course of their disease. However, if the disease is localized, then complete surgical resection remains the standard of cure and the best chance for cure. On occasion, these tumors involve a significant portion of both the distal esophagus and proximal stomach.

MATERIALS AND METHODS

In order to completely remove these tumors with an adequate surgical margin and lymph node dissection, a total gastrectomy and total esophagectomy with colonic interposition may be required. We have utilized this approach on six patients with excellent clinical results. In this manuscript, we discuss the technical considerations involved in this approach and present our results.

Thoracoabdominal incision: a forgotten tool in the management of complex upper gastrointestinal complications

BACKGROUND

The gastroesophageal junction was commonly approached surgically through a thoracoabdominal incision. With the advent of improved retraction devices, this has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity. However, exposure of the gastroesophageal junction remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation.

METHODS

Patients were placed in the right lateral decubitus position. An incision was made 2 cm below the tip of the scapula to a point in the midline equidistant from the xiphoid process to the umbilicus. The chest was entered at the eighth intercostal space. The abdominal cavity was entered by dividing the diaphragm peripherally from its lateral attachments to the ribs.

RESULTS

We have used this approach on 4 patients. All patients were discharged home tolerating oral diets. The average postoperative stay was 10 days. No complications related to the incision were reported. At the 6-month follow-up evaluation all patients continued to tolerate a regular diet without difficulties.

CONCLUSIONS

The technique described allows for excellent exposure of the upper gastrointestinal tract in a subset of patients with complex upper gastrointestinal complications.

Benefit of mediastinal and para-aortic lymph-node dissection for advanced gastric cancer with esophageal invasion

BACKGROUND AND OBJECTIVES

Lymph-node dissection in gastric cancers with esophageal invasion (AGCE) is of current interest. This study examined the significance of inferior mediastinal lymph-node (IM) and para-aortic lymph-node (PA) dissection for this type of cancer.

METHOD

Two hundred and seventy cases of AGCE were clinicopathologically reviewed. An index of estimated benefit from lymph-node dissection (IEBLD) was calculated from the frequency of lymph node metastasis in IM and PA, and from 5-year survival rates for metastatic cases.

RESULTS

Among the cases of AGCE, IM and PA metastasis rates were 18.1% and 22.2%, respectively. The IEBLD for IM and PA was similar to that for dissection of the second-tier lymph nodes around the celiac axis. The IM metastasis rate was 0.0% for esophageal invasion of 0-9 mm, 2.2% for 10-19 mm, 17.8% for 20-29 mm, and 21.7% for 30-39 mm of esophageal invasion.

CONCLUSION

AGCE is associated with a high rate of PA metastasis, and with a high rate of IM metastasis when esophageal invasion exceeds 2 cm. Since dissection of IM and PA achieved the same benefit as dissection of second-tier lymph nodes, we recommend thorough dissection of these lymph nodes.

Endoscopic ultrasound predicts outcomes for patients with adenocarcinoma of the gastroesophageal junction

BACKGROUND

Endoscopic ultrasound (EUS) is the most accurate locoregional staging tool for gastroesophageal junction (GEJ) adenocarcinoma, and it may allow pretreatment risk stratification. The purpose of this study was to compare preoperative EUS staging with postoperative pathologic staging and to assess the ability of EUS to predict survival after resection for GEJ adenocarcinoma.

STUDY DESIGN

Patients with GEJ adenocarcinoma, who had preoperative staging with EUS followed by resection, were identified from a prospectively maintained database. Patients receiving neoadjuvant therapy were excluded. EUS stage was compared with pathologic stage. Survival analyses were performed in patients who underwent complete gross resection.

RESULTS

From 1985 through 2003, 209 patients underwent preoperative EUS followed by surgery without neoadjuvant therapy for GEJ adenocarcinoma. EUS correlated with pathologic T stage in 128 of 209 (61%) patients and with pathologic nodal stage in 154 of 206 (75%) patients. EUS accurately stratified patients into "early" (T0-2 N0) or "advanced" (T3-4 or N1) disease categories in 173 (83%) patients. Curative (R0) resection was performed in 184 patients: EUS "early" (n=84) and "advanced" (n=122) stages were associated with R0 rates of 100% and 82%, respectively (p=0.001). EUS "early" versus "advanced" stage was highly predictive of outcomes (p < 0.0001). The 5-year disease-specific survival for EUS "early" patients was 65% compared with 34% for EUS "advanced" stage.

CONCLUSIONS

EUS accurately predicts pathologic stage. In addition, EUS is predictive of outcomes after complete gross resection without neoadjuvant treatment for GEJ adenocarcinoma and identifies a high-risk population that might benefit from preoperative therapy.

Proposal for a new definition of true cardia carcinoma

BACKGROUND AND OBJECTIVES

It remains controversial whether cardia carcinoma should be categorized and treated as esophageal cancer or gastric cancer. The purpose of this study was to develop a reasonable definition of cardia carcinoma.

METHODS

Patients with Siewert type II carcinomas were divided into two subgroups: 25 patients with a tumor center within 1 cm of the esophagogastric junction (EGJ) (type IIA) and 22 patients with tumor center 1-2 cm aboral of the EGJ (type IIB). Patients with subcardia carcinomas, 40 with invasion to the EGJ (type III) and 110 without (type IIIe-), were used as controls.

RESULTS

The patients with type IIB carcinomas showed no different characteristics from those with type III or type IIIe- carcinomas, except for the stage of the disease. On the other hand, those with type IIA carcinomas were associated with a higher male/female ratio, higher incidences of elevated appearance, differentiated histology, and mediastinal node metastasis, and a significantly lower survival rate as compared with patients with subcardia carcinomas. Multivariate survival analysis revealed that type IIA is a significant prognostic determinant, but that type IIB is not.

CONCLUSION

Type IIA carcinomas should be treated as true cardia carcinoma; type IIB as subcardia carcinoma. Our results should be confirmed by a prospective study.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Adenocarcinoma of the esophagogastric junction: surgical therapy based on 1602 consecutive resected patients

Because of the borderline location between the esophagus and stomach, many discrepancies exist in the current literature regarding the etiology, classification, and surgical treatment of adenocarcinoma arising at the esophagogastric junction. The classification of adenocarcinomas into three types, AGE type I, type II, and type III, shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are recommended for a good, long-term prognosis. With better surgical management and standardized procedures, even the results in patients with more radical surgical approaches, the abdomino-thoracic esophagectomy improved.

Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction

The left thoraco-abdominal (LTA) esophago-gastrectomy is rarely performed and yet provides excellent exposure of the esophageal hiatus. The aim of this study was to review the outcome of LTA esophago-gastrectomy within a single unit. Patients were selected for an LTA esophago-gastrectomy (January 2000 - June 2003) based upon the presence of locally advanced tumors of the distal esophagus and cardia. These patients were identified from a prospective consultant database. LTA esophagogastrectomy was technically possible in all 38 patients (34 males; median age = 63 years). In-hospital mortality was 2.6% (1 patient). Four patients (10.5%) were admitted to the intensive care unit and three (7.9%) returned to theatre. Two patients developed clinically apparent anastomotic leaks (5.3%). A potentially curative resection was performed in 34 patients (89%) but 22 (57.8%) of these patients were subsequently found to have tumor cells at or within 2 mm from the circumferential resection margin. The 1-year and 2-year overall survival rates were 70% and 52%, respectively. Long-term complications included benign anastomotic stricture (24%), delayed gastric emptying (26%) and a persistent thoracic wound sinus (15%). LTA esophagogastrectomy remains a viable approach with an acceptably low incidence of short and long-term complications.

Adenocarcinoma of gastric cardia in the elderly: Surgical problems and prognostic factors

AIM: To analyze retrospectively, our results about patients who underwent surgical treatment for adenocarcinoma of the cardia in relation to age, in order to evaluate surgical problems and prognostic factors.

METHODS: From January 1987 to March 2003, 140 patients with adenocarcinoma of the cardia underwent resection in the authors’ institution. They were divided into three groups with regard to age. Patients <70 and >60 year old (31) were excluded; we also excluded 18 out of 109 patients with poor general status or systemic metastases. So, we compared 51 elderly (≥ 70 year old) and 58 younger patients (≤ 60 year old). The treatment was esophagectomy for type I tumors, and extended gastrectomy and distal esophagectomy for type II and III lesions.

RESULTS: Laparotomy was carried out in 91 patients (83.4%), 38 in the elderly (74.5%) and 53 in younger patients (91.3%, P<0.05). Primary resection was performed in 81 cases (89%) without significant differences between the two groups. Postoperative death was higher in the elderly (12.1%) than the other group (4.1%, P<0.05), while morbidity was similar in both groups. A curative resection (R0) was performed in 59 patients (72.8%), 69.6% in the elderly and 75% in the younger group (P>0.05). The overall 3- and 5-year survival rates were 26.7% and 17.8% respectively for the elderly and 40.7% and 35.1% respectively for younger patients (P = 0.1544). Survival rates were significantly associated with R0 resection, pathological node-positive category and tumor differentiation in both groups.

CONCLUSION: As the age of the general population increases, more elderly patients with gastric cardia cancer will be candidates for surgical resection. Age alone should not preclude surgical treatment in elderly patients with gastric cardia cancer and a tumor resection can be carried out safely. Certainly, we should take care in defining the surgical treatment in elderly patients, particularly as regarding the surgical approach; although the surgical approach does not influence the survival rate, the transhiatal way still remains the best one due, to the lower incidence of respiratory morbidity and thoracic pain.

Biologic and clinical variations of adenocarcinoma at the esophago-gastric junction: relevance of a topographic-anatomic subclassification

A topographic-anatomic subclassification of adenocarcinomas of the esophago-gastric junction (AEG) in distal esophageal adenocarcinoma (AEG Type I), true carcinoma of the cardia (AEG Type II), and subcardial gastric cancer (AEG Type III) was introduced in 1987 and is now increasingly accepted and used worldwide. Our experience with now more than 1,300 resected AEG tumors indicates that the subtypes differ markedly in terms of surgical epidemiology, histogenesis and histomorphologic tumor characteristics. While underlying specialized intestinal metaplasia can be found in basically all patients with AEG Type I tumors, this is uncommon in Type II tumors and virtually absent in Type III tumors. Stage distribution and overall long-term survival after surgical resection also shows marked differences between the AEG subtypes. Surgical treatment strategies based on tumor type allow a differentiated approach and result in survival rates superior to those reported with other approaches. The subclassification of AEG tumors thus provides a useful tool for the selection of the surgical procedure and allows a better comparison of treatment results.

E-cadherin expression as predictive marker of proximal resection line involvement for advanced carcinoma of the gastric cardia

AIMS

Total gastrectomy for gastric cardia tumours harbours a high risk of proximal resection line (PRL) involvement. The adhesion markers CD44v6 and E-cadherin were evaluated as predictive factors for PRL involvement independent of tumour stage.

METHODS

Forty-nine gastrectomy specimens for gastric cardia carcinoma (type II) were evaluated for stage, resection margins, and CD44v6 and E-cadherin immunohistochemistry.

RESULTS

PRL involvement was microscopically recognized in 49% of specimens. CD44v6 expression was found in 84% of intestinal tumours, and in 56% of diffuse/mixed tumours (p=0.045). In the group of resections performed with curative intent, the proximal extension of the resection (margin) was significantly shorter in E-cadherin negative tumours than in E-cadherin positive tumours (p=0.029). Histological type and stage of the tumour, lymph node metastases, and absence of E-cadherin expression, but not the presence of CD44v6 correlated with PRL involvement. Only the absence of E-cadherin expression appeared to be a significant predictor of PRL involvement, independent of tumour stage. Survival for patients with PRL involvement was shorter than that for patients after R0 resection (p=0.07). Stage was the only independent prognostic factor emerging from multivariate survival analysis (p=0.002).

CONCLUSIONS

When curative resection is intended in type II cardiac cancer patients, an oesophageal resection and gastric tube reconstruction should be considered, especially for a tumour without E-cadherin expression.

Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma

Background

The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma.

Methods

Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of 99mTc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld γ probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases.

Results

SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P &lt; 0·001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P &lt; 0·001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0·018), radioactive uptake (P &lt; 0·001) and malignant nodes (P = 0·004) in the mediastinum than gastric cardia tumours.

Conclusion

The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Prospective study of routine contrast radiology after total gastrectomy

BACKGROUND

The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation.

METHODS

Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy.

RESULTS

Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

CONCLUSION

There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction

AIMS

The optimal extent of oesophageal resection and surgical approach in patients treated for adenocarcinomas of the oesophagogastric junction (OGJ) are still uncertain. We report the correlations between resection margin involvement and outcome.

METHODS

Patients with positive proximal resection margin (PPRM) and those with negative proximal resection margin (NPRM) were compared.

RESULTS

Of 94 patients with macroscopically complete resection, eight were PPRM. There was no difference between the two groups in postoperative mortality or morbidity rates, in anastomotic leakage or in recurrence rates. The median survival in the PPRM group was 11.1 months compared with 36.3 months in the NPRM group (P=0.02). No infiltration was observed in patients whose proximal margin exceeded 7 cm. The extended transthoracic approach was the only prognostic factor for tumours type II (P=0.03, RR=1.4, 95% CI: 1.1-1.8).

CONCLUSION

Histologic infiltration of oesophageal resection margin influences 5-year survival rate. In adenocarcinomas of the OGJ that can be treated curatively, a transection with a 8 cm oesophagectomy above the tumour in fresh specimen should be performed, and by thoracoabdominal approach for tumours type I and II.

Surgical management of and long-term survival after adenocarcinoma of the cardia

BACKGROUND

The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions.

METHODS

From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively.

RESULTS

Fifty-six patients (44.4 per cent) had type I tumours, 44 (34.9 per cent) type II and 26 (20.6 per cent) type III. Primary resection was performed in 113 patients (89.7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51.6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48.4 per cent). In-hospital mortality and morbidity rates were 4.8 and 34.1 per cent respectively. The overall 3- and 5-year survival rates were 40.9 and 25.1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation.

CONCLUSION

Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches.

Adenocarcinoma of the Gastric Cardia: Treatment via a Left Thoracoabdominal Approach

We examined the outcome of adenocarcinomas of the gastric cardia treated by total or proximal gastrectomy, lower esophagectomy, and D2 lymphadenectomy via a left thoracoabdominal approach. We compare these results with those of other methods as well as review the literature. During a 10-year period (1991–2000) 180 patients with primary gastric cancer were admitted to our department. Thirty-six of the patients had adenocarcinoma of the cardia. Twenty-four patients underwent total gastrectomy, D2 lymphadenectomy, and esophagectomy, and four others underwent proximal gastrectomy and esophagectomy with esophagogastric anastomosis via a left thoracoabdominal approach. These latter 28 patients compose our study group. We had no operative mortality, the morbidity varied, and the quality of life and the loss of body weight ranged within satisfactory levels, but the survival rate was rather poor. The median survival time was 19 ± 1.2 months. Survival was significantly longer in patients with less than 40 per cent positive resected lymph nodes ( P = 0.035). From the resulting data and our experience we believe that the left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of such tumors. This approach combined with total gastrectomy and D2 lymphadenectomy can be performed with an acceptably low mortality rate; it provides good palliation but not encouraging survival rates. Although it is less radical proximal gastrectomy gives the same results and a better quality of life but may be performed only in the early stages of the disease.

The pattern of recurrence of adenocarcinoma of the oesophago-gastric junction

Knowledge of the pattern of recurrence of surgically treated cases of adenocarcinoma of the oesophago-gastric junction is important both for better understanding of their biological nature and for future strategic planning of therapy. The aim of this study is to demonstrate and compare the pattern of dissemination and recurrence in patients with Type I and Type II adenocarcinoma of oesophago-gastric junction. A prospective audit of the clinico-pathological features of patients who had undergone surgery with curative intent for adenocarcinoma of oesophago-gastric junction between 1991 and 1996 was undertaken. Patients were followed up by regular clinical examination. Clinical evaluation was supported by ultrasound, computerised tomography, radio-isotope bone scan, endoscopy and laparotomy each with biopsy and histology where appropriate. One hundred and sixty-nine patients with oesophago-gastric junction tumours (94 Type I and 75 Type II) have been followed up for a median of 75.3 (57-133) months. One hundred and three patients developed proven recurrent disease. The median time to recurrence was 23.3 (14.2-32.4) months for Type I and 20.5 (11.6-29.4) for Type II cancers. The most frequent type of recurrence was haematogenous (56% of Type I recurrences and 54% of Type II) of which 56% were detected within 1 year of surgery. The most frequent sites were to liver (27%), bone (18%) brain (11%) and lung (11%). Local recurrence occurred in 33% of Type I cancer and 29% of Type II recurrences. Nodal recurrence occurred in 18 and 25% of Type I and Type II cancer recurrences, most frequently to coeliac or porta hepatis nodes (64%). Only 7% of Type I and 15% of Type II cancer recurrences were by peritoneal dissemination. Type I and Type II adenocarcinoma of the oesophago-gastric junction have a predominantly early, haematogenous pattern of recurrence. There is a need to better identify the group of patients with small metastases at the time of diagnosis who are destined to develop recurrent disease in order that they may be spared surgery and those with micro metastases in order that they can be offered multi-modality therapy including early post operative or neo-adjuvant chemotherapy.

Surgical therapy for adenocarcinoma of the cardia: modalities of recurrence and extension of resection

In order to define the optimal extent of resection for cancer of the cardia, we considered 116 patients operated upon with five different surgical techniques. The procedures were: transabdominal total gastrectomy associated with distal esophagectomy in 38 patients; transabdominal total gastrectomy and left thoracotomic esophageal resection at the inferior pulmonary vein level in 26 patients; transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level in 27 patients; transabdominal total gastrectomy and transhiatal lower third esophagectomy in 18 patients; transhiatal total esophagectomy and upper third gastrectomy with cervical esophago-gastroplasty in seven patients. Grading, staging, neoplastic lymphangitis, satellite intramural metastases, infiltration of the resection margin, site of recurrence, and survival were analyzed. N+ was the single independent prognostic factor for survival. A poorly differentiated grading was related to T (P = 0.0009), N (P = 0.001), satellite growth (P = 0.05), and infiltration of the resection margin (P = 0.0001). Recurrence was local in 26% and distant in 74% of patients. The modalities of recurrence were not related to the aggressiveness parameters and the surgical technique. Infiltration of the esophageal resection margin was related to the type of operation (P = 0.005) and survival (P = 0.02), but it was not related to the site of recurrence. Transabdominal total gastrectomy and the right thoracotomic esophageal resection procedure achieved free margins and control of the lymph nodal metastatic spread. Transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level provides a radical oncologic resection, particularly in poorly differentiated tumors. However, surgery alone cannot cure the majority of adenocarcinomas of the cardia.

Validation of a modified GTNM classification in peri-junctional oesophago-gastric carcinoma and its use as a prognostic indicator

AIM

A modified GTNM classification (with additional T and N subdivisions) has been used for many years. The aim of this paper was to validate this classification in a group of patients with oesophago-gastric carcinoma and to see if the more detailed information may be useful.

METHOD

The 3-year survival of 139 consecutive patients who survived resection has been related to the individual values of the modified and international classifications.

RESULTS

A step-wise reduction in the survival was found with increasing values of G, T, N and M. The international T3 value yielded a 17.7% survival rate, when subdivided, rates of 37.5%, 17.3% and 3.2% were found. The international N1 value yielded a rate of 12.9% which subdivided into rates of 25.0%, 18.7% and 7.5%.

CONCLUSION

If these results are repeated in a larger and more detailed study, this modified classification may provide added information when discussing prognosis and management.

A new technique for esophagojejunostomy after total gastrectomy for gastric cancer

BACKGROUND

The critical part of any operation involving a proximal gastric resection is the esophageal anastomosis. Leakage from this anastomosis is one of the main reasons for postoperative morbidity and death after gastrectomy. Application of the double-stapling technique affords many of the same advantages that it does for low rectal tumors, especially in obese patients with narrow costal margins.

METHODS

A new technique for esophagojejunostomy after total gastrectomy for gastric cancer is described.

RESULTS

This technique has been used in 3 patients. At a follow-up of 22 months, there have been no anastomotic leaks or evidence of clinical stenoses.

CONCLUSIONS

This technique minimizes manipulation and dissection around the distal esophagus. Not only does this make the operation easier, but it also allows for a longer proximal resection margin. Possibly this will result in lower rates of esophageal breakdown.

The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction.

METHODS

The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately.

RESULTS

One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion (P =.002).

CONCLUSIONS

The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined.

Surgical treatment of gastric cancer invading the oesophagus

INTRODUCTION

There is controversy regarding which type of surgical treatment is most appropriate for upper gastric cancer invading the oesophagus.

METHODS

A review of the pertinent literature was carried out regarding oesophageal involvement in gastric cancer.

RESULTS

Invasion of the oesophagus occurred in 26-63% of Western surgical series. It was more frequent in Borrmann IV type, linitis plastica, pT3-pT4, diffuse type by Lauren, N+ or tumours exceeding 5 cm in diameter. Lymphatic tumour spread was caudad (coeliac nodes, hepatoduodenal nodes, paraortic nodes) but mediastinal nodes were also involved if tumour growth in the oesophagus exceeded 3 cm or if there was transmural oesophageal infiltration. In Western countries there was less than 30% 5-year survival and no long-term survivors when hepatoduodenal or mediastinal nodes were metastatic. Mediastinal dissection through thoracotomy did not provide any benefit.

CONCLUSIONS

A rational approach involves total gastrectomy plus partial oesophagectomy. Abdominal transhiatal resection may be performed in the case of a localized, non-infiltrating tumour and oesophageal involvement <2 cm. However, infiltrating, poorly differentiated or Borrmann III-IV tumours require a right thoracotomy to achieve a longer margin of clearance. When oesophageal involvement is >3 cm, or hepatoduodenal or mediastinal nodes are positive, no surgical procedure is curative and the literature demonstrates that extended aggressive surgery has no benefits.

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE

To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction.

SUMMARY BACKGROUND DATA

Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial.

METHODS

In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors.

RESULTS

There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.

Esophageal cancer

Papers published in the English literature on esophageal cancer in 1999 were retrieved by a MEDLINE search. Selective publications were reviewed in light of current knowledge. Many studies were performed to refine staging methods of esophageal cancer, especially in the use of endoscopic ultrasound. Although better designs have overcome the problem of nontraversable tumors, its use in staging after neoadjuvant therapies remains suboptimal. Important studies on various surgical techniques were reported, including randomized trials on different routes of reconstruction after esophageal extirpation, and the updated results of transhiatal resections. In contrast to the minimalist approach of transhiatal resection, investigators from both East and West have also described the pathologic basis of lymphatic spread of esophageal cancer and its implications, favoring more radical lymphadenectomy. Another avenue that was explored is the use of neoadjuvant therapies to improve outcome. Different regimens were studied, and many papers focused on the molecular prediction of favorable response to such therapies. Overenthusiastic adoption of multimodality treatments is cautioned, however, in that they have not been validated. Further work is much needed in this area of research.

Adenocarcinoma of the gastroesophageal junction in Japan: relevance of Siewert's classification applied to 177 cases resected at a single institution

BACKGROUND

There had been a lack of international consensus about the definition of cancer of the gastric cardia until Siewert's classification was approved at a consensus conference during the second International Gastric Cancer Congress held in 1997.

STUDY DESIGN

A review of the prospective gastric cancer database at Aichi Cancer Center from 1983 to 1992 identified 1,913 gastric carcinoma patients who underwent gastrectomy. These patients were classified retrospectively according to the Siewert classification, and 177 patients who fell into one of the three types form the basis of this study. Survival analyses were performed after stratifying patients by clinicopathologic variables.

RESULTS

There were 33 patients with type II and 144 with type III, although none had type I, a type frequently observed in the west. No evidence of a change in the frequency of types II or III cancers (approximately 9.3% overall) among gastric carcinoma patients was observed over the 10-year period. Clinical staging of gastric carcinoma by the TNM classification was found to reflect accurately the prognosis of these patients. There were no longterm survivors among the few patients with metastasis to the perigastric nodes of the distal stomach.

CONCLUSIONS

A striking difference in the distribution of types of adenocarcinoma of the gastroesophageal junction was observed in Japan compared with previously reported western data. A subgroup of carcinoma of the proximal stomach identified as types II and III may not require proximal gastrectomy from the viewpoint of sufficient lymphadenectomy.