Esophagogastric Junction Tumors Research Articles

803. 2-YEAR RESULTS IN ESOPHAGOGASTRIC JUNCTION CANCER TREATMENT

Abstract Background Esophagogastric junction (EGJ), also known as cardia, tumors have unique characteristics with a widespread of lymph node (LN) metastatic patterns influenced by the extent of esophageal involvement. Besides, there is no worldwide consensus about its classification and the optimal lymphadenectomy and surgical resection extend. Recently, mapping the distribution of LN metastasis in these patients could provide some insights about the extent that should be the target. Furthermore, the balance between resection extension and the procedure safety is also difficult to achieve. This work aims to review the last 2 years of EGJ tumor treatment in a single oncological center. Methods We present a retrospective, single center study that included all the patients with EGJ cancer undergone surgical resection between 2022 and 2023. These tumors were classified using our modified Siewert (mSiewert) classification based on mapping endoscopy with measures of the full extension and not only the tumor’s epicenter. Patient demographics, tumor characterization, neoadjuvant treatment, surgical procedure and postoperative results were assessed, alongside with pathological and oncological metrics as recurrence, disease-free survival (DFS) and overall survival (OS). Results We included 64 cardia cancer patients who underwent a curative treatment strategy, with a median age of 68 years, mostly men (87.5%), with a median BMI of 25 kg/m2. 68.2% were classified as ECOG-PS 0 however 62.5% were classified as ASA III-IV. Most tumors were moderately (39.2%) or poorly (31.4%) differentiated adenocarcinomas. Majority were locally advanced (cT3, 78.1%) and in stage III (85.9%). Regarding tumor location, 49.2% were classified as mSiewert I-II (49.2%), followed by I-II-III (18%) and II-III (18%). 36.1% had esophageal involvement ≥4cm, 87.5% received neoadjuvant treatment split between the CROSS and FLOT protocols. Our resection rate was 85.9%. We mostly performed Mckeown esophagectomy (49.1%) and transhiatal esophagectomy (18.2%). We had a 12.7% admission rate to the intensive care unit and a 27.3% major complication rate (Clavien-Dindo ≥ 3b). Anastomotic dehiscence occurred in 16.4% of cases, with hospital mortality rate of 3.6%. The median hospital stay was 6 days, with a 16.4% readmission rate. Pathological staging revealed that 47.3% were stage III, with a median lymph node yield of 28 and a 98.2% R0 resection rate. Most patients received adjuvant treatment, primarily FLOT protocol or Nivolumab, in 38.2% and 29.1%, respectively. The recurrence rate was 28%, with a median time to recurrence of 26 weeks, mainly occurring as distant metastasis pattern (64.3%). One-year overall survival (OS) was 88.7%, and one-year disease-free survival (DFS) was 66.4%, with a median follow-up time of 48 weeks and only a 3.6% loss to follow-up rate. Conclusion This study highlights the unit’s adaptation of EGJ tumor treatment to new insights, emphasizing the importance of comprehensive classification and multimodal and multidisciplinary approach to enhance patient outcomes.

Safety of robotic double-flap technique following proximal gastrectomy in the introductory phase compared with laparoscopic procedure: a propensity score-matched analysis.

Proximal gastrectomy (PG) is recommended for upper-third gastric cancer and esophagogastric junction (EGJ) cancer, preserving organ function while reducing postoperative symptoms. The double-flap technique (DFT) is one approach to minimize reflux after PG. However, laparoscopic PG with DFT (LPG-DFT) has drawbacks of increased complexity, such as hand sutures for anastomosis. Robotic surgery offers potential advantages for DFT reconstruction, but the safety of robotic DFT following PG (RPG-DFT) in the introductory phase is unknown. This retrospective study compared the outcomes of RPG-DFT with LPG-DFT. Data from 402 patients (321 LPG-DFT, 81 RPG-DFT) between 2009 and 2023 were analyzed. Propensity score matching balanced patient demographics and tumor characteristics. Surgical parameters, complications, and long-term outcomes were assessed. The surgery time of LPG-DFT has stabilized in patients since 2016. Thus, LPG-DFT from 2016 was defined as a stable procedure. RPG-DFT was started in 2019, after minimally invasive DFT reconstruction had been mastered at our center. Therefore, we compared the surgical outcomes of introductory RPG-DFT with stable LPG-DFT. Matched analysis revealed that RPG-DFT in the introductory phase had significantly longer surgery times but less bleeding and shorter reconstruction times and hospital stays than stable LPG-DFT. Frequencies of short-term complications and reflux esophagitis were comparable in both groups. Although RPG-DFT in the introductory phase exhibited higher incidence of anastomotic stenosis than stable LPG-DFT, the incidence of anastomotic stenosis decreased over time. This study demonstrated the safety of RPG-DFT in the introductory phase for EGJ and upper-third stomach tumors, with outcomes comparable to stable LPG-DFT. RPG-DFT offers shorter reconstruction time and less blood loss compared with LPG-DFT. However, anastomotic stenosis is a complication to monitor in early robotic surgery.

Lymph node metastases in middle and upper mediastinum of Siewert type II adenocarcinoma: A real-world retrospective study.

To explore whether the upper and/or middle mediastinal nodes (UMMN) should be dissected in Siewert type II adenocarcinoma (AC) according to the incidence of lymph node metastasis. Additionally, to investigate the association between the length of esophageal involvement (LEI) and the UMMN metastases. A cohort with Siewert type II AC who were operated on by a surgical team that routinely treated esophagogastric junction (EGJ) tumors with esophagectomy and extended lymphadenectomy were assessed retrospectively. The primary endpoint of the research was the metastasis rate of UMMN. A total of 94 patients with EGJ tumor from July 2018 to September 2022 were enrolled. Station 106recR (6.4%, 6/94) was the only station among upper mediastinal nodes (UMN) that presented positive nodes. Middle mediastinal nodes (MMN) metastases of station 107, 109 and station 108 were 2.1% (2/94) and 5.0% (4/80), respectively. Among the 11 patients with MMN or UMN metastases, 63.6% (7/11) had lesser than seven metastatic nodes, and 54.5% (6/11) had a pathological N stage ≤2. LEI >3 cm (p = 0.042) showed a higher risk for MMN metastases in univariable logistic analysis. However, no independent risk factor for mediastinal node metastases was detected. This study demonstrated that the incidence of positive MMN and UMN is relatively low in resectable Siewert type II AC, which indicated that it is not necessary to perform a routine dissection upon these stations. LEI >3 cm might be associated with higher risk for mediastinal node metastasis. Certain patients could benefit from extended lymphadenectomy since most of the patients with positive MMN or UMN have a limited number of metastatic nodes.

Factors Associated with Mediastinal Lymph Node Positivity in Proximal Gastric Tumor Patients Undergoing Curative Surgery

Background: Gastric cancer is the fifth most common cancer worldwide. Objectives: This study investigated the risk factors associated with mediastinal lymph node metastases due to proximal gastric cancer. Methods: The study included patients with curative surgical resection and transcural lymphadenectomy for proximal gastric tumors between January 2012 and January 2020. The patients (n=88) were divided into Group 1 (n=54, negative) and Group 2 (n=34, positive) according to the positivity of mediastinal lymph nodes. The diagnostic value of composite immunonutritional and inflammatory indices in predicting lymph node positivity was examined. Results: It was found that only C-reactive protein (CRP) (P=0.044), the rate of postoperative respiratory complications (P=0.002), tumor size (P=0.0001), the total number of lymph nodes, and the number of metastatic lymph nodes were higher in Group 2. Moreover, pT stage (P=0.008) and pN stage (P<0.001) were more advanced in Group 2. Among the composite indices, only the neutrophil-to-lymphocyte ratio (NLR) had a diagnostic value, with a sensitivity of 67.65% and a specificity of 55.56% at a cut-off point of > 2.19. According to the multivariate analysis, a tumor size of > 3 cm, a CRP value of > 7, and tumor localization were independent risk factors. Conclusion: Our study found that mediastinal lymph node positivity was associated with elevated CRP and that these patients had more advanced tumors and poor histopathological characteristics. Mediastinal lymph node positivity was also associated with increased postoperative respiratory complications. We established the diagnostic value of the NLR in predicting lymph node positivity. It is helpful to establish the relationship between clinicopathological characteristics and mediastinal lymph node positivity in proximal gastric tumors since it can be useful in determining the surgical strategy for esophagogastric junction tumors.

Navigating the complexities of developing a classification of esophagogastric junction tumors suitable for preoperative setting.

Despite the worldwide decrease in the incidence of gastric cancer, the proportion of occurrence of carcinomas of the esophagogastric junction and proximal third of stomach is on the rise. The cause of this development is believed to lie in an increasing incidence of reflux esophagitis with Barrett´s metaplasiaand successful eradication ofHelicobacter pyloriinfection. The aim of this work is to present various views on the definition of the esophagogastric junction itself and to give an overview of tumor classification schemes being used (Fig. 2, Ref. 54). Keywords: gastric cancer, esophagogastric junction, definition, classification.

When Gastroplasty Is Not Feasible in Ivor Lewis Esophagectomy: A Single-Center Study of Intrathoracic Esophagojejunostomy.

Objective: The surgical management of tumors of the esophagogastric junction is increasingly performed by minimally invasive Ivor Lewis esophagectomy. However, gastroplasty is not always feasible. The creation of a long loop is an alternative for esophageal reconstruction. The aim of this study was to evaluate the technical feasibility of using a minimally invasive thoracoscopic approach in esophagojejunostomy and to describe the contraindications for gastroplasty. Methods: All patients who had intrathoracic esophagojejunostomy in our center were identified in our database. Since 2016, the preferred approach for intrathoracic esophagojejunostomy is minimally invasive laparoscopy and thoracoscopy, using a long Roux-en-Y jejunal loop with a semimechanical triangular anastomosis technique. Results: Between January 1, 2012 and January 1, 2022, 12 patients who had esophagojejunostomy in our center were included in the study. Among them, 6 had thoracotomy and 6 had total minimally invasive thoracoscopy, representing 3.5% of surgical procedures for esophagogastric junction tumors since 2016. The mean operative time was 416.9 ± 107.47 minutes. No anastomotic leakage was observed in the minimally invasive group versus 2 leakages in the thoracotomy group. The main complication was pneumonia in 3 patients (27.3%). Finally, the main indication for intrathoracic esophagojejunostomy was tumor size with a mean of 4.72 ± 2.35 cm and the patient's surgical history. Conclusion: A total minimally invasive approach using a long jejunal loop with triangular anastomosis could be a feasible and reproducible alternative to gastroplasty to restore continuity in Ivor Lewis esophagectomy when the stomach cannot be used.

P-130 Latin American population with adenocarcinoma of the esophagogastric junction: A 9-year follow up

Esophagogastric junction (EGJ) adenocarcinoma represents 27% of gastric tumors with an increasing incidence in Western countries. Additionally, up to 80% of EGJ tumors are diagnosed in advanced stages of disease, therefore the prognosis is usually poor, with a 5-year overall survival rate of less than 30%. It is known that EGJ tumors are an entity with its own epidemiological characteristics, biological behavior, and prognosis, without evidence to support optimal management. The aim of this study was to describe clinicopathological features, treatment, and outcome of Latin American patients with EGJ adenocarcinoma treated at the National Cancer Institute.

Evidence-based approach to the treatment of esophagogastric junction tumors.

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing in developed nations due to the rising prevalence of obesity and gastroesophageal reflux disease. Due to the peculiar location in a histological transition zone between the esophagus and the stomach, the management of EGJ tumors is controversial. Two main surgical approaches exist: total gastrectomy with distal esophagectomy or esophagectomy by either transhiatal or transthoracic approach. These operations differ significantly in the extent of lymphadenectomy. In addition, patients with locally advanced disease can receive either preoperative chemoradiation or perioperative chemotherapy. This evidence-based review analyzes current evidence regarding the management of EGJ tumors in order to help defining the best surgical and systemic treatment of these patients.

Tocilizumab in SARS-COVID19 following postoperative laparoscopic transhiatal esophagectomy for the adenocarcinoma of esophagogastric tumor: A case report.

Introduction and importanceEsophagectomy for esophageal cancer is one of the most challenging surgical procedures, with high rates of morbidity, especially from respiratory complications. SARS-COVID19 represents a health threat nowadays. Peri-operative SARS-COVID19 infection after esophagectomy might negatively affect the postoperative outcomes. The use of tocilizumab as an alternative to reduce the inflammatory response in SARS-COVID19 is an option that has not been described in the literature after esophagectomy.Case presentationA SARS-COVID19-vaccinated (CORONAVAC) 73-year-old man with pulmonary emphysema, coronary artery disease, previous asymptomatic pulmonary embolism, and adenocarcinoma of the esophagogastric junction tumor was submitted to laparoscopic transhiatal esophagectomy (ypT2N0M0) after perioperative neoadjuvant chemotherapy. He was also infected with SARS-COVID19, confirmed by PCR test at the 14th postoperative day. During follow-up, mild hypoxemia persisted without evidence of infection except for SARS-COVID19, and a high-flow cannula was required to maintain oxygenation. Tocilizumab was administered following high parameters of a high-flow cannula, and invasive mechanical ventilation was avoided.DiscussionBesides of the risk of secondary infection, after administration of tocilizumab, the parameters of oxygen supplementation were systematically reduced, and he stayed in the ICU for seven days. He was discharged from the ward six days later. He developed late cervical anastomotic leakage, which was treated with conservative therapy.ConclusionAlthough the patient had high-risk comorbidities, esophagectomy, and SARS-COVID19 infection, the use of tocilizumab was safe and improved the pulmonary recovery.

Thoracoscopic esophagectomy is related to better outcomes in early adenocarcinoma of esophagogastric junction tumors.

BACKGROUNDThoracoscopic esophagectomy is related to an extended lymphadenectomy, and a high number of retrieved lymph nodes, compared to the transhiatal approach; however, its association with an improvement in overall survival (OS) is debatable. AIMTo compare thoracoscopic esophagectomy with transhiatal esophagectomy in patients with adenocarcinoma of the esophagogastric junction (AEGJ) in terms of survival, number of lymph nodes, and complications. METHODSIn total, 147 patients with AEGJ were selected retrospectively from 2002 to 2019, and divided into Group A for thoracoscopic esophagectomy, and group B for transhiatal esophagectomy. OS, disease-free survival, postoperative complications, and number of nodes, were similarly evaluated.RESULTSOne hundred and thirty (88%) were male; the mean age was 64 years. Group A had a mean age of 61.1 years and group B 65.7 years (P = 0.009). Concerning the extent of lymphadenectomy, group A showed a higher number of retrieved lymph nodes (mean of 31.89 ± 8.2 vs 20.73 ± 7; P < 0.001), with more perioperative complications, such as hoarseness, surgical site infections, and respiratory complications. Although both groups had similar OS rates, subgroup analysis showed better survival of transthoracic esophagectomy in patients with earlier diseases. CONCLUSIONBoth methods are safe, having similar morbidity and mortality rates. Transthoracic thoracoscopic esophagectomy allows a more extensive resection of the lymph nodes and may have better oncological outcomes during earlier stages of the disease. Prospective studies are warranted to better evaluate these findings.

Esophagogastric junction adenocarcinoma: Preoperative chemoradiation or perioperative chemotherapy?

Multimodal treatment is currently the standard of care for locally advanced esophagogastric junction (EGJ) adenocarcinoma due to poor results after surgery alone. Neoadjuvant therapy is intended to shrink the tumor and eliminate potential circulating tumor cells. However, which neoadjuvant treatment is best for patients with EGJ tumors remains controversial. We aimed to compare outcomes of preoperative chemoradiation and perioperative chemotherapy for EGJ adenocarcinomas. For this purpose, we performed a thorough review of the literature describing neoadjuvant treatments for EGJ adenocarcinomas or comparing both therapies. Although some studies have shown better locoregional control and higher rates of complete pathologic response after chemoradiation, data suggest that both types of neoadjuvant therapy have similar survival benefits. As current data are heterogeneous and many studies have included significantly different types of patients in their analysis, future studies with better patient selection are still needed to define which neoadjuvant therapy should be chosen. In addition, targeted therapies and immunotherapy have promising results and should be further explored.

Serum CYR61 as a potential biomarker for the diagnosis of esophagogastric junction tumor.

Background: Esophagogastric junction tumor (EGJ) is a rare but fatal disease with a rapid rising incidence worldwide in the late 20 years, and it lacks a convenient and safe method for diagnosis. The present study aimed to evaluate the potential of serum CYR61 as a biomarker for the diagnosis of EGJ tumor.Methods: Enzyme-linked immunosorbent assay (ELISA) was used to estimate CYR61 levels in sera of 152 EGJ tumor patients and 137 normal controls. Receiver operating characteristics (ROC) was carried out to evaluate the diagnostic accuracy. The Mann–Whitney’s U test was used to compare the difference of serum levels of CYR61 between groups. And chi-square tests were employed to estimate the correlation of the positive rate of serum CYR61 between/among subgroups.Results: Serum CYR61 levels were statistically lower in EGJ tumor and early-stage EGJ tumor patients than those in normal controls (P<0.0001). The sensitivity, specificity and the area under the curve (AUC) of this biomarker in EGJ tumor were 88.2%, 43.8% and 0.691, respectively, and those for early stage of EGJ tumor were 80.0%, 66.4% and 0.722, respectively. Analyses showed that there was no correlation between the clinical data and the levels of CYR61 (P>0.05).Conclusion: The present study showed that CYR61 might be a potential biomarker to assist the diagnosis of EGJ tumor.

Analysis of the clinical confusion and controversy of esophagogastric junction tumor from basic anatomy

There are still many controversies in the surgical treatment of esophagogastric junction tumors in terms of surgical approach, cleaning range, and resection scope. The reason is the confusion about the scope of the esophagogastric junction. The previous domestic and foreign anatomy descriptions of this part are not enough to solve the current problems. Based on a large number of basic anatomy and clinical operations, this article proposes that the esophagogastric junction may be wrapped by a complete and separate esophagogastric junction membrane with independent anatomy other than infracardiac bursa. The structure of the transitional tissue, mainly from the distribution of submucosal veins, explained the relationship and significance of tissue transitional changes and clinical operations, and made a reasonable analysis of the current controversy based on the anatomical characteristics, which is worthy of further investigation.

ESOPHAGEAL CANCER IN SOUTH INDIA; AN INSTITUTIONAL 5-YEARS RETROSPECTIVE ANALYSIS ON ITS CLINICOPATHOLOGY AND RISK FACTORS OF DISTANT METASTASIS

Context: Esophageal cancer (EC) is highly fatal malignancy with considerable geographical variation in its distribution, etiologies, histopathological subtypes, and mortality. Methods: A retrospective analysis was performed to study the clinicopathology, and risk factors of distant metastasis (DM) among 255 cases of EC treated between January 2015 and December 2019 in a tertiary cancer center in south India. Statistical analysis: Chi-square test and multivariate analysis (MVA) were used for analysis. P &lt; 0.05 was considered signicant. Results: The median age at diagnosis of EC was 57 years, higher for male. Younger EC patients (≤ 40 years) constituted 8.2%, and were commonly female, non-smoker, non-alcoholic, squamous cell carcinoma (SCC). Male: female ratio was 1.67:1. Lower thoracic esophagus was the commonest site. SCC was the commonest histology. Adenocarcinoma (ADC) was common among older age, male, esophagogastric junction (EGJ), high grade tumor, and carried higher risk of DM. ADC had higher propensity for liver metastasis, whereas SCC for lung metastasis. MVA showed the risk factors associated with DM were poor performance status (PS), delayed diagnosis, EGJ tumor, ADC histology, high grade tumor. Conclusion: Lower thoracic esophageal location and SCC histology remains the commonest type of EC in southern part of India. Younger EC patients are commonly female, nonsmokers, non alcoholic, SCC. ADC is common in male, older age. EGJ tumor are commonly ADC, high grade, and carries higher risk of DM, which warrants early diagnosis, aggressive systemic therapy in this subset of patients for improving the survival.

Laparoscopic lymph node sampling: a new concept for patients with high-risk early esophagogastric junction cancer resected endoscopically

Endoscopic resection is considered a curative treatment for early upper GI cancers under certain histologic (low-risk) criteria. In tumors not completely fulfilling these criteria but resected R0 endoscopically, esophagectomy is still advised because of an increased risk of lymph node (LN) metastases (LNM). However, the benefit-risk ratio, especially in elderly patients at higher risk for radical surgery, can be debated. We now present the outcome of our case series of laparoscopic LN sampling (LLS) in patients with T1 esophagogastric junction tumors, which had been completely resected by endoscopy but did not fulfill the low-risk criteria (G1/2, m, L0, V0). Retrospective review was done of all patients with T1 cancer undergoing LLS with at least 1 high-risk parameter after endoscopic resection during an 8-year period. Repeated endoscopy with biopsy and abdominothoracic CT had been performed before. The patients were divided into 2 periods: before (n= 8) and after (n= 12) the introduction of an extended LLS protocol (additional resection of the left gastric artery). In cases of positive LN, patients underwent conventional oncologic surgery; if negative, follow-up was performed. The main outcome was the number of harvested LNs by means of LLS and the percentage of positive LNs found. Twenty patients with cardia (n= 1) and distal esophageal/Barrett's cancer (n= 19) were included. The LN rate with use of the extended LLS technique increased by 12% (period 1: median 12 [range, 5-19; 95% CI, 3.4-15.4] vs period 2: median 17.5 [range, 12-40; 95% CI, 12.8-22.2]; P= .013). There were 2 adverse events: 1 inadvertent chest tube removal and 1 postoperative pneumonia. In 15% of cases, patients had positive LNs. and in 2 cases there was local recurrence at the endoscopic resection site, all necessitating surgery. An extended technique of laparoscopic LN sampling appears to provide adequate LN numbers and is a safe approach with short hospital stay only. Only long-term follow-up of larger patient numbers will allow conclusions about miss rate as well as oncologic adequacy of this concept.

Safety and feasibility of laparoscopic double-flap technique in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction tumors larger than 5 cm

Objective: To investigate the safety and feasibility of laparoscopic double-flap technique (Kamikawa) in digestive tract reconstruction after proximal gastrectomy for esophagogastric junction (EGJ) leiomyoma and gastrointestinal stromal tumor (GIST) with the maximum diameter >5 cm. Methods: A descriptive case-series study was used to retrospectively analyze the data of patients with EGJ leiomyoma and GIST undergoing laparoscopic-assisted proximal gastrectomy and double-flap technique (Kamikawa) at the Department of Gastrointestinal Surgery, Guangdong Hospital of Traditional Chinese Medicine from September 2017 to March 2019. All the tumors invaded the cardia dentate line, and the maximum diameter was >5 cm. After the exclusion of patients requiring emergency surgery and complicating with severe cardiopulmonary diseases, a total of 4 patients, including 3 males and 1 female with age of 29-49 years, were included in this study. After laparoscopic-assisted proximal gastrectomy, the residual stomach was pulled out of the abdominal cavity and marked with methylene blue at the proximal end 3~4 cm from the anterior wall of the residual stomach in the shape of "H". The gastric wall plasma muscular layer was cut along the "H" shape, and the space between the submucosa and the muscular layer was separated to both sides along the longitudinal incision line to make the seromuscular flap. The residual stomach was put back into the abdominal cavity. Under laparoscopy, 4 stitches were intermittently sutured at the upside of "H" shape and 4-5 cm from the posterior wall of the esophageal stump. The stump of the esophagus was cut open, and the submucosa and mucosa were cut under the "H" shape to enter the gastric cavity. The posterior wall of the esophageal stump was sutured continuously with the gastric stump mucosa and submucosa under laparoscopy. The anterior wall of the esophageal stump was sutured continuously with the whole layer of the residual stomach. The anterior wall of the stomach was sutured to cover the esophagus. The anterior gastric muscle flap was sutured and embedded in the esophagus to complete the reconstruction of digestive tract. The morbidity of intraoperative complications and postoperative reflux esophagitis and anastomosis-related complications were observed. Results: All the 4 patients completed the operation successfully, and there was no conversion to laparotomy. The median operative time was 239 (192-261) minutes, the median Kamikawa anastomosis time was 149 (102-163) minutes, and the median intraoperative blood loss was 35 (20-200) ml. The abdominal drainage tube and gastric tube were removed, and the fluid diet was resumed on the first day after surgery in all the 4 patients. The median postoperative hospitalization time was 6 (6-8) days. Postoperative pathology revealed 3 leiomyomas and 1 GIST. There were no postoperative complications such as anastomotic leakage or stenosis, and no reflux symptoms were observed. The median follow-up time was 22 (11-29) months after the operation, and no reflux esophagitis occurred in any of the 4 patients by gastroscopy. Conclusion: For >5 cm EGJ leiomyoma or GIST, double-flap technique (Kamikawa) used for digestive tract reconstruction after proximal gastrectomy is safe and feasible.

Immunohistochemical Staining With Neuroendocrine Markers is Essential in the Diagnosis of Neuroendocrine Neoplasms of the Esophagogastric Junction.

Neuroendocrine neoplasms (NENs) of the esophagogastric junction (EGJ) are uncommon and the classification of these tumors has been revised several times. Since 2016, at the Department of Pathology, Rigshospitalet, Denmark, all adenocarcinomas and poorly differentiated carcinomas of the EGJ have been stained routinely with the neuroendocrine markers, synaptophysin and chromogranin A, to detect a possible neuroendocrine component. This study aimed to determine if routine immunohistochemical staining is necessary to detect neuroendocrine differentiation of the EGJ tumors by evaluating how often a neuroendocrine component of the tumors was correctly identified or missed on routine hematoxylin and eosin-stained slides, and by evaluating the interobserver agreement among several pathologists. Of 262 cases a NEN was identified in 24 (9.2%). Up to 22.7% of all EGJ NENs would have been missed without routinely performed neuroendocrine staining in all EGJ tumors. The interobserver agreement between 3 pathologists was slight to moderate. In conclusion, immunohistochemical staining with neuroendocrine markers is essential for the diagnosis of NENs, and to detect all NENs, we recommend to perform this routinely on all resected tumors of the EGJ.

Current status of anti-reflux surgery of proximal gastrectomy for esophagogastric junction tumor

In recent years, the overall incidence of gastric cancer has been decreasing worldwide, while the incidence of the esophagogastric junction tumor is increasing year by year. With the progress of the diagnostic technology of upper gastrointestinal tumors and the gradual popularization of early cancer screening, the detection rate of early esophagogastric junction tumor keeps increasing. Therefore, in recent years, the clinical application of gastric function preserving surgery is gradually increasing. As an important part of the surgical treatment strategy of esophagogastric junction tumors, proximal gastrectomy has attracted more and more attention with the confirmation of oncological safety. Compared with total gastrectomy, patients after proximal gastrectomy have better nutritional status and quality of life. However, the high incidence of reflux esophagitis after traditional proximal gastrectomy has seriously affected the quality of life of patients, and also hindered the application of proximal gastrectomy in esophagogastric junction tumors. How to reduce the occurrence of reflux esophagitis after proximal gastrectomy by optimizing the method of digestive tract reconstruction has been a big challenge in clinical practice. This article reviews the current methods of anti-reflux surgery for proximal gastrectomy for esophagogastric junction tumors, aiming to provide a reference for choosing a reasonable anti-reflux surgery.

Is laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor at the esophagogastric junction safe?

With technique improvements, indications for laparoscopic and endoscopic cooperative surgery (LECS) for gastric subepithelial tumor (SET) are gradually expanding for tumors technically difficult to resect. However, surgical outcomes of LECS, including for esophagogastric junction (EGJ) tumors requiring advanced skills, remain unknown. We reviewed patients in whom LECS had initially been attempted for gastric SET at the Cancer Institute Hospital in Tokyo from June 2006 to May 2018. Indications for LECS at the EGJ have gradually expanded during the study period to include tumors with esophageal invasion up to 2 cm, or less than half the EJG circumference, preoperatively. Surgical outcomes and risk factors for conversion to other procedures were investigated. Twenty (9.3%) of the 214 total patients had EGJ tumors. Four patients (20%) with EGJ tumors developed postoperative complications (Clavien-Dindo grade ≥ II). Among 12 patients in whom LECS could be completed for EGJ tumors, only one non-serious complication occurred. Eight patients required conversion to another operation for EGJ tumors (two laparotomy, six proximal gastrectomy). Among conversion cases with EGJ tumors, anastomotic leakage occurred in both patients undergoing laparotomy after LECS, necessitating additional defect closure. There was only one non-serious complication in six proximal gastrectomy patients. On multivariate analysis, EGJ tumor was an independent risk factor for conversion to another operation. LECS at the EGJ may be a risk factor for conversion operation, and when performing LECS at the EGJ is difficult, conversion to proximal gastrectomy, which can be performed safely, should be considered.

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.