Can proximal Gastrectomy Be Justified for Advanced Adenocarcinoma of the Esophagogastric Junction?

Long-Term Outcome of Proximal Gastrectomy for Upper-Third Advanced Gastric and Siewert Type II Esophagogastric Junction Cancer Compared With Total Gastrectomy: A Propensity Score-Matched Analysis

BACKGROUND

This study aimed to investigate the oncologic long-term safety of proximal gastrectomy for upper-third advanced gastric cancer (AGC) and Siewert type II esophagogastric junction (EGJ) cancer.

METHODS

The study enrolled patients who underwent proximal gastrectomy (PG) or total gastrectomy (TG) with standard lymph node (LN) dissection for pathologically proven upper-third AGC and EGJ cancers between January 2007 and December 2018. Propensity score-matching with a 1:1 ratio was performed to reduce the influence of confounding variables such as age, sex, tumor size, T stage, N stage, and tumor-node-metastasis (TNM) stage. Kaplan-Meier survival analysis was performed to analyze oncologic outcome. The prognostic factors of recurrence-free survival (RFS) were analyzed using the Cox proportional hazard analysis.

RESULTS

Of the 713 enrolled patients in this study, 60 received PG and 653 received TG. Propensity score-matching yielded 60 patients for each group. The overall survival rates were 61.7 % in the PG group and 68.3 % in the TG group (p = 0.676). The RFS was 86.7 % in the PG group and 83.3 % in the TG group (p = 0.634). The PG group showed eight recurrences (1 anastomosis site, 1 paraaortic LN, 1 liver, 1 spleen, 1 lung, 1 splenic hilar LN, and 2 remnant stomachs). In the multivariate analysis, the operation method was not identified as a prognostic factor of tumor recurrence.

CONCLUSION

The patients who underwent PG had a long-term oncologic outcome similar to that for the patients who underwent TG for upper-third AGC and EGJ cancer.

Therapeutic value of lymph node dissection for Siewert type II and III adenocarcinoma: meta-analysis

BACKGROUND

Adenocarcinoma of the oesophagogastric junction presents an increasing incidence. Surgical resection with lymphadenectomy is the only curative treatment modality at the present time, but the optimal extent of lymphadenectomy is debatable. The aim of the present meta-analysis was to estimate the therapeutic value of each nodal station.

METHODS

Studies reporting the therapeutic value index of each nodal station in Siewert types II/III oesophagogastric junction (EGJ) were searched in PubMed, Web of Science and Embase up to October 2022. This index was calculated by multiplication of metastatic incidence and 5-year overall survival rate at each nodal station. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Pooled metastatic incidence and therapeutic value index were calculated using RevMan 5.4.

RESULTS

Twelve studies involving 3513 patients were included. Nodes No. 3, 1, 7 and 2 were routinely dissected and achieved a high (≥10) or moderate (5-10) therapeutic value index in decreasing order, due to their high metastatic incidence and favourable survival rate. The index was relatively low (2-5) in suprapancreatic nodes No. 9, 11p and 8a. The index for nodes No. 4d and 10 was relatively low in Siewert type Ⅲ EGJ but very low (<2) in type Ⅱ. The index was very low for nodes No. 5, 6, 11d and 12a, due to their low metastatic incidence and poor survival if positive. Para-aortic, parahiatal and mediastinal nodes were dissected only in highly selected cases. Dissection of the lower mediastinal nodes, especially No. 110, could improve survival rates in type Ⅱ EGJ.

CONCLUSION

These data could help assess the optimal extent of lymphadenectomy for EGJ. Nodes No. 1, 2, 3, 7, 8a, 9 and 11p need routine dissection in both Siewert types Ⅱ/Ⅲ EGJ; nodes around the lower oesophagus (especially No. 110) in Siewert type Ⅱ EGJ and nodes No. 4d and 10 in Siewert type Ⅲ EGJ might be considered for dissection.

Indication of Proximal Gastrectomy for Advanced Proximal Gastric Cancer Based on Lymph Node Metastasis at the Distal Part of the Stomach

Objective

To suggest the possible indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

Background

Proximal gastrectomy has been an alternative surgical procedure for early proximal gastric cancer due to its benefits for quality of life while maintaining oncological outcomes. However, the oncological safety of proximal gastrectomy for advanced tumors remains unclear.

Methods

We retrospectively reviewed data from 878 patients who underwent radical total gastrectomy from 2003 to 2018 for pathologic T2-T4 gastric cancer in the upper third of the stomach. We identified risk factors for lymph node metastasis at the distal part of the stomach, which was not dissected in proximal gastrectomy. Subsequently, we evaluated the metastasis rate and therapeutic value index of lymph nodes at the distal part of the stomach in patients with none of these risk factors.

Results

Multivariable analysis revealed that esophagogastric junction (EGJ)-tumor epicenter distance >30 mm, tumor size >70 mm, macroscopic type IV tumor, and serosal invasion were risk factors for lymph node metastasis at the distal stomach. In patients without risk factors, the therapeutic value index for any lymph nodes at the distal stomach was 0.8, suggesting that lymph node dissection could be omitted in these patients.

Conclusions

EGJ-tumor epicenter distance ≤ 30 mm, tumor size ≤ 70 mm, not a macroscopic type IV tumor, and no serosal invasion could be an indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

Clinical significance of lower perigastric lymph nodes dissection in Siewert type II/III adenocarcinoma of esophagogastric junction: a retrospective propensity score matched study

PURPOSE

The optimal surgical procedure, whether total gastrectomy (TG) or proximal gastrectomy (PG), for Siewert type II/III adenocarcinoma of esophagogastric junction (AEG) has not been standardised, primarily because the optimal extent of lymph node (LN) dissection for AEG based on the metastatic rate of perigastric LNs remains under debate. The aim of this study was to investigate the metastatic incidence and prognostic significance of lower perigastric lymph nodes (LPLN), including No.4d, 5, 6 and 12a LN stations, in Siewert type II/III AEG.

METHODS

A total of 701 patients with Siewert type II/III AEG who received transabdominal open gastrectomy (425 patients with TG and 276 patients with PG) from 2010 to 2015 in West China Hospital were retrospectively included. Based on the clinicopathological information of TG patients, the risk factors of LPLN-positive patients were evaluated, and the metastatic incidence as well as the therapeutic value (TV) index of each LN station was assessed. Moreover, the 5-year overall survival (OS) rates between LPLN-positive and LPLN-negative groups were compared in TG patients, and the postoperative survival difference between TG and PG patients was also compared, using propensity score matching (PSM) method.

RESULTS

Tumour size (≥ 5 cm, OR = 1.481, p = 0.002) and pT stage (pT4, OR = 2.755, p = 0.024) were significant risk factors for patients with LPLN metastasis. For patients with tumour size more than 5 cm or pT4 stage, the metastatic rates of LPLN for Siewert type II, III and II/III AEG were 31.67%, 34.69% and 33.03%, whereas the TV indexes of LPLN for them were 5.76, 5.62 and 5.38, respectively. LPLN was a significant independent prognostic factor (HR = 1.422, p = 0.028), and positive LPLN was related to worse prognosis (p < 0.05). For patients with tumour size more than 5 cm or pT4 stage, TG patients were illustrated to have a better prognosis than PG patients, with 5-year OS rates of 58.9% vs 38.2% for Siewert type II AEG (χ2 = 4.159, p = 0.041), 68.9% vs 50.2% for Siewert type III AEG (χ2 = 5.630, p = 0.018) and 65.1% vs 40.3% for Siewert type II/III AEG (χ2 = 12.604, p < 0.001), respectively.

CONCLUSIONS

LPLN metastasis is a poor prognostic factor for patients with Siewert II/III AEG. LPLN dissection may improve the long-term survival of patients with tumour size more than 5 cm or pT4 stage, and TG might be more suitable for this kind of cancer.

Proximal gastrectomy may be a reasonable choice for patients with selected proximal advanced gastric cancer: A propensity score-matched analysis

BACKGROUND

Whether proximal gastrectomy (PG) can be applied to patients with proximal advanced gastric cancer (AGC) remains controversial. We aimed to explore the oncological safety of PG for proximal AGC in this study.

METHODS

452 patients undergoing surgery for proximal AGC in the Affiliated Cancer Hospital of Nanjing Medical University were enrolled in this study. 329 patients with AGC were finally analyzed, of which 254 patients underwent total gastrectomy (TG) and 75 patients underwent PG. We used propensity score-matched (PSM) analysis to reduce biases.

RESULTS

After PSM, 67 patients with proximal AGC were included in the PG group and TG group, respectively. The estimated 5-year OS rates for TG and PG group after PSM were 64.3% and 74.9%, respectively, and no significant difference in OS existed between the two groups (p = 0.275). Multivariate analysis showed that PG was not an independent prognostic factor. Incidence of metastasis in No.5 or 6 lymph node (LN) station was significantly higher in the patients with pathological T4 and Borrmann III tumors (9.9% and 10.6%) than those with pathological T2/3 and Borrmann I/II tumors (2.2% and 3.3%). No metastasis was observed in No.5 or 6 LN station in patients with pathological T2/3 tumors or Borrmann I/II tumors when tumor size was ≤4 cm.

CONCLUSIONS

PG is a reasonable choice for patients with selected proximal AGC, especially for those with tumors of size ≤4 cm, Borrmann type I/II, and pathological T2/3. Future prospective randomized trials should be conducted first in patients with these specific proximal tumors.

The Results of Sentinel Node Mapping for Patients with Clinically Early Staged Gastric Cancer Diagnosed with pT2/deeper Tumors

BACKGROUND

Sentinel node (SN) mapping based on the SN concept has been applied to early gastric cancer. However, it is still controversial whether or not the oncological safety is ensured in case pathological stage was advanced in these patients. The aim of this study was to investigate the validity of SN mapping in patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors.

METHODS

We retrospectively analyzed 40 patients with a diagnosis of cT1N0 or cT2N0 single-lesion gastric cancer who were shown to have pT2 or deeper tumors after gastrectomy with SN mapping. We adopted a dual-tracer method using a radioactive colloid and blue dye to detect SNs. The diagnostic accuracy and distribution of SNs at each tumor site were analyzed.

RESULTS

Of the 40 patients, 24 (60%) were postoperatively diagnosed as pT2, and 16 (40%) as pT3 or T4. SNs were detected in all patients. The false negative rate was 9% (1/11), and in that patient, the non-SN metastasis was observed within the SN basin. Diagnostic accuracy was 98% (39/40). Overall distribution of SNs was similar to that for patients with early gastric cancer. No significant differences in overall and recurrence-free survival were observed between the patients who underwent standard gastrectomy and those who underwent function-preserving gastrectomy, based on the results of SN mapping.

CONCLUSIONS

Our results confirmed validity of SN mapping for patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors after gastrectomy. Closed surveillance without additional surgical treatment is an option for these patients.

A novel method of esophagogastrostomy by overlap anastomosis with placement of the remnant stomach into the lower mediastinum after laparoscopic proximal gastrectomy

INTRODUCTION

Control of postoperative gastroesophageal reflux (GER) is a critical consideration for patients who undergo proximal gastrectomy. This report describes a new and simple reconstruction method by esophagogastrostomy with placement of the remnant stomach into the lower mediastinum (EG-PRIME). This approach not only suppresses postoperative GER, but it can also be easily performed by total laparoscopy. Detailed herein are the methods for EG-PRIME and the results for three patients with cancer of the upper gastric body.

MATERIALS AND SURGICAL TECHNIQUE

At the start of the EG-PRIME surgical procedure, a pseudo-fornix and lozenge-shaped gastric conduit were made by cutting the stomach diagonally. Next, the pseudo-fornix was inserted into the esophageal hiatus to form a new angle of His. Then overlap anastomosis was performed and the entry site was closed longitudinally. The outcomes assessed were operative time, intraoperative blood loss, postoperative complications and GER according to 24-hour pH monitoring.

DISCUSSION

The operative times were 339, 288 and 236 minutes; in two patients, intraoperative blood loss was 260 and 343 mL, and in the third, blood loss was minimal. No postoperative complications were observed in any of the three patients. The degree of the GER resulting in fraction time pH<4 was 9.0%, 0.3%, and 2.9%, respectively. No esophagitis by upper gastrointestinal endoscopy was observed in any patient. This EG-PRIME method was technically feasible for reconstruction after proximal gastrectomy by total laparoscopy. This approach may be as simple and useful as esophagogastrostomy for preventing postoperative GER, but more experience with this method is required.

Oncologic Feasibility of Proximal Gastrectomy in Upper Third Advanced Gastric and Esophagogastric Junctional Cancer

Purpose

The aim of this study was to investigate the oncologic safety and identify potential candidates for proximal gastrectomy (PG) in upper third advanced gastric cancer (AGC) and esophagogastric junction (EGJ) cancers.

Materials and Methods

Among 5,665 patients who underwent gastrectomy for gastric adenocarcinoma between January 2011 and December 2017, 327 patients who underwent total gastrectomy with standard lymph node (LN) dissection for upper third AGC and Siewert type II EGJ cancers were enrolled. We analyzed the correlation between the metastatic rates of distal LNs (No. 4d, 5, 6, and 12a) around the lower part of the stomach and the clinicopathological characteristics. We identified subgroups with no metastasis to the distal LNs.

Results

The metastatic rate of distal LNs in proximal AGC and Siewert type II EGJ cancers was 7.0% (23 of 327 patients). On multivariate analysis, pathological T stage (P=0.001), tumor size (P=0.043), and middle third invasion (P=0.003) were significantly associated with distal LN metastases. Pathological ‘T2 stage’ (n=88), or ‘T3 stage with ≤5 cm tumor size’ (n=87) showed no metastasis in distal LNs, regardless of middle third invasion. Pathological T3 stage with tumor size > 5 cm (n=61) and T4 stage (n=91) had metastasis in the distal LNs.

Conclusions

In the upper third AGC and Siewert type II EGJ cancer, pathological T2 and small-sized T3 stage groups are possible candidates for PG in cases without distal LN metastasis. Further validation studies are required for clinical application.

The surgical procedure for esophagogastric junction cancer — discussing the tactics

Introduction. Currently, there is no standardized surgical tactics for the esophagogastric junction cancer treatment. The issues of the resection margin, volume of lymphodissection and the optimal size of the gastric stump are still being discussed. This article analyzes the influence of these parameters on the recurrence-free survival and postoperative quality of life for patients, according to the literature data. Objective. Analysis of the treatment outcomes for patients with esophagogastric junction cancer, depending on the surgical tactics. Materials and Methods. The article analyzes the literature data evaluating various approaches in the surgical treatment of esophagogastric junction cancer. We present an example (from the Yasuyuki Seto study) of a patient with proximal gastric adenocarcinoma with a depth of T3 invasion and the surgical tactics regarding the size of the gastric stump. a A great advantage of the resection margin located at 2 cm from the proximal margin and at 5 cm from the distal margin has been shown. According to the results of our own observations, a patient with proximal gastric adenocarcinoma with an invasion depth of T3 underwent a resection with the proximal and distal resection margins of 13 and 65 mm, respectively. Negative resection margins were diagnosed intraoperatively. The patient's recurrence -free survival was 6 years. A total gastrectomy or esophagectomy are not the operations of choice because of the worsening of the patient's quality of life. When analyzing the depth of invasion according to the literature data, it has been found that an invasion in the esophagus of more than 30 mm is associated with an increased risk of metastatic lymph nodes of the superior and middle mediastinum. With a gastric invasion length of more than 40 mm, lymph nodes of lesser curvature along the right gastric artery are affected. According to the literature, a gastric stump with the size of more than two-thirds of the organ size was favorable in terms of the postoperative quality of life. Many authors indicate the positive effect of maintaining the gastroesophageal sphincter and cardia of the stomach. In the study by Yasuyuki Seto, proximal gastric resection was applied only if it was possible to maintain more than 12 cm in the small curvature and 25 cm in the large curvature. Conclusion. When choosing the surgical tactics for the esophagogastric junction cancer, one needs to focus on the patient's quality of life after the surgery. It is necessary to achieve negative resection margins in each case. The resection margins should be more than 2 and 5 cm for the proximal and distal margins, respectively. Dissection of the lymph nodes of the middle and superior mediastinum should be carried out with invasion of the tumor into the esophagus by more than 30 mm, removal of the lymph nodes of the lesser curvature of the stomach along the right gastric artery must be carried out if the tumor invasion into stomach is more than 40 mm. It is optimal to keep the gastric stump equal to two-thirds of the size of the organ. The issue of the surgical tactics in cancer of the esophageal-gastric transition is of great practical importance and requires a further study.

How to decide surgical procedure for esophagogastric junction cancer?

Standard surgical procedure for esophagogastric junction cancer, especially adenocarcinoma, has still remained controversial. Various procedures has been allowed and applied for Siewert type II tumors. Negative long resection margin had been regarded as essential in decision on the procedure. Recent papers have, however, shown the priority of invasion length to each side (esophagus and stomach), because it relates the frequency and sites of lymph node metastasis to be dissected. And, the size of remnant stomach is, also, important when a proximal gastrectomy is considered.

Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy

Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The ‘dorsal track control’ (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.