Abstract
BackgroundThe choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours.MethodsA retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months).ResultsA total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1–79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach.ConclusionSurgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.
Highlights
The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another
A transabdominal technique is applicable to surgical resection of tumours of the gastric cardia/ fundus (Siewert type III), a number of different approaches have been employed for surgical resection of cancer of the distal oesophagus and Siewert type I and II gastro-oesophageal junction (GOJ) tumours
Tumour location Analysis was focused on oesophageal tumours in the distal third of the oesophagus (>33 cm ab orum) and type I and II tumours of the GOJ according to the Siewert classification [2]: It is claimed that the surgical approach used for these tumours may influence the ability to obtain tumour clearance and impact upon survival
Summary
The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. The Ivor Lewis transthoracic and transhiatal approaches have been compared in patients with oesophageal cancer in terms of duration of procedure, hospital stay, postoperative outcome and survival, with no obvious benefit to either approach [3,4,5,6,7,8] These studies include three randomised controlled trials and show no significant difference in rates of anastomotic leakage, postoperative mortality or survival between the approaches [4,5,6]. Three studies have addressed tumours of the distal oesophagus, GOJ and gastric cardia, with only Sasako et al, noting a higher morbidity in patients undergoing the left thoraco-laparotomy approach in comparison to transhiatal techniques [8,9,10]. Population based figures from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), showed that there was little difference in outcome between the three commonest operative approaches for oesophageal cancer i.e. transhiatal, Ivor Lewis and left thoraco-laparotomy [11]
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