Esophagogastric Junction Research Articles

FUNCTIONAL POSSIBILITIES OF ESOPHAGEAL-GASTIC ANASTOMOSIS IN THE REMOTE POSTOPERATIVE PERIOD ACCORDING TO THE DATA OF THE MORPHO-FUNCTIONAL STUDY

Resume. Purpose: Morpho-functional assessment of the method of endoprosthesis of failure of the esophageal-gastric anastomosis sutures in the distant postoperative period. Introduction. Currently, views on treatment tactics in the case of the inability to suture esophageal anastomoses are contradictory and have diametrically opposite opinions — from extremely gentle to extremely aggressive. Optimism of supporters of palliative resections is due not only to the almost identical mortality with radical operations, which is 4.0-31.6%, but also to the possibility of ensuring 5-year survival of 8.5-15.7% of operated patients. Thus, a number of questions remain relevant, including the study of morpho-functional shifts in tissue cells of the esophageal-gastric anastomosis with the assessment of its functional capabilities in the distant postoperative period based on morphological research. Material and methods. The work was performed in the Department of Surgery of the Gastrointestinal Tract and Esophagus of the State University «IZNG named after V.T. Zaitsev National Academy of Medical Sciences of Ukraine» with the presentation of the results of a morpho-functional study and statistical analysis of the treatment of patients with the development of failure of esophageal-intestinal anastomoses in the postoperative period. All patients were fitted with self-expanding stents, stents from M.I.Tech Co., Ltd. (Korea), covered esophageal HANAROSTENT with an antireflux valve - 14 and Boston Scientific Corp. were used for endoprosthetics. (USA), covered with Ultraflex-2 esophagus. In the long-term period, all patients discharged from the hospital underwent a control X-ray and endoscopic examination every 1-2 months, during which a biopsy was performed and material was taken for the next morphological examination. For light microscopy, tissue fragments of the esophageal-gastric junction were fixed in a 10% solution of neutral formalin for 24 hours at a temperature of +20°C, after which they were dehydrated with ethyl alcohol and embedded in paraffin. Sections were prepared from paraffin blocks and stained with Ehrlich’s hematoxylin and eosin. Research results. The long-term results of endoprosthesis of failed esophageal-gastric anastomosis sutures in 43 stented patients were evaluated. Of great interest is the morpho-functional state of the esophageal-gastric anastomosis in the long term after surgery (3- 24 months), as these terms determine the functional capabilities of the anastomosis. Taking into account that during the research it is possible to detect initial morpho-functional shifts in the tissues of the examined organs, it should be assumed that in the future hypoxia of the stomach and esophagus increases and the degree of expressiveness of these disorders maintains the same sequence. Conclusions. The conducted studies expanded the understanding of the pathogenesis of morpho-functional disorders occurring in the distant postoperative period, confirmed the priority of metabolic disorders in tissue cells in diseases of the gastrointestinal tract, and also allowed to give a prognostic assessment of the functional possibilities of the further development of the gastric process. further tactics of managing patients at the next stage of treatment.

Four-Dimensional Impedance Manometry in Esophageal Motility Disorders.

Four-dimensional high-resolution impedance manometry (4D HRM) uses impedance to estimate esophageal luminal cross-sectional area and track nadir impedance to measure intrabolus pressure (IBP). We aimed to determine whether 4D HRM metrics could define abnormal esophagogastric junction (EGJ) opening between Chicago Classification version 4.0 motility disorders and compare 4D HRM with functional lumen imaging probe (FLIP) metrics. Symptomatic adult patients who completed high-resolution impedance manometry and FLIP were included and compared with an asymptomatic control group. 4D HRM analysis used custom-built software to measure IBP, maximum EGJ diameter, and distensibility index on supine test swallows. 4D HRM metrics were compared with FLIP EGJ metrics. Ninety patients (31 normal motility, 16 ineffective esophageal manometry, 9 absent contractility, 8 conclusive EGJ outflow obstruction [EGJOO], 12 type I achalasia, 14 type II achalasia, 12 type III achalasia, and 34 asymptomatic controls) were included. Phase 2 and 3 IBP was higher in type II and III achalasia compared with controls and normal motility groups ( P < 0.03). Maximum EGJ diameter and EGJ-distensibility index in the conclusive EGJOO and achalasia groups were significantly lower than in controls and normal motility groups ( P < 0.03). 4D HRM identified 37 of 44 (84%) subjects with normal EGJ opening and 29 of 39 (74%) subjects with reduced EGJ opening on FLIP. 4D HRM metrics correlated with expected clinical observations across a spectrum of esophageal motility disorders and defined EGJ obstruction. 4D HRM metrics may have value in defining EGJ obstruction in equivocal cases related to EGJOO or absent peristalsis.

Pulse Granuloma in Esophagus; A Rare finding in Achalasia Patient: Case Report and Literature Review

Abstract Introduction/Objective Pulse granuloma is a granulomatous reaction to foreign body, most commonly to food material. This is clinically silent and incidental but may be confused for a mass like lesion. This can be found any location in gastrointestinal tract but most reported in oral cavity and colon. We herein report a rare case of pulse granuloma in esophagus with literature review of the entity. Methods/Case Report A 58-year-old male with history of achalasia, surgical history of Heller myotomy, hernia reduction, hiatoplasty, gastropexy, vagotomy, presented with recurrent stricture of the esophagogastric junction. The patient received multiple esophageal balloon dilatations in the past due to high esophageal sphincter pressure and was complicated by severe reflux associated with esophagitis and large hiatal hernia. He underwent subtotal esophagectomy due to dysphagia. Gross examination of the esophagectomy specimen showed multiple previous procedure scars and was opened to reveal firm yellow food particles impacting in the mucosa. Histological examination showed gastroesophageal junctional mucosa with ulceration and fibrosis of the muscularis propria. Pink ribbon like hyalinized foci with giant cell was found which stained negative for GMS, PAS and AFB, supporting the diagnosis of pulse granuloma. Literature search for key word ‘Pulse Granuloma’ identified thirty-five case reports from year 1977 to 2024, with most reported case in the oral cavity (14 cases, 42%). Out of ten cases reported in gastrointestinal tract, 1 case was reported in small bowel and 9 cases were reported in colon and rectum and no cases were reported in esophagus. Results (if a Case Study enter NA) NA Conclusion Our patient’s history of achalasia and dysphagia along with histopathologic findings supports diagnosis of pulse granuloma in esophagus. Although clinically silent, pulse granuloma may cause mass-like lesions and result in enlargement and stenosis. In setting of esophageal achalasia recognizing this entity is important as it can mimic malignancy and other mass-forming lesions.

Efficacy of the U‐shaped flap technique in preventing reflux after minimally invasive proximal gastrectomy for proximal gastric and esophagogastric junction cancer

Efficacy of the U‐shaped flap technique in preventing reflux after minimally invasive proximal gastrectomy for proximal gastric and esophagogastric junction cancer

Botulinum toxin injection of the lower esophageal sphincter to identify achalasia-variant esophagogastric junction outflow obstruction.

Esophagogastric junction outflow obstruction (EGJOO) can be an achalasia variant caused by neuromuscular dysfunction of the lower esophageal sphincter (LES), or the manometric manifestation of mechanical processes that impair EGJ distensibility. Distinction among these conditions has important implications for treatment, but can be difficult. We hypothesized that response to botulinum toxin (BT) injection of the LES could be a diagnostic test for identifying achalasia-variant EGJOO likely to respond to LES muscle-directed invasive therapy. We reviewed our experience with symptomatic EGJOO patients who had BT injection of the LES. Data collected include demographics, esophageal body manometry findings, esophagram evidence of retention, and symptom response at 1-6months after BT injection categorized as poor, partial, or good. Clinical response to any subsequent LES-directed invasive treatment (EsoFLIP dilation, pneumatic dilation, Heller myotomy, or POEM) also was recorded. Thirteen symptomatic EGJOO patients were included (mean age 55.9 ± 16.4years; eight men, five women). Symptom response to BT injection was good in six (46%), partial in three (23%), and poor in three (23%); one was lost to follow-up. All five patients who received invasive treatment after partial or good response to BT had a partial or good response to invasive treatment. The one patient who had invasive treatment after a poor response to BT had a poor response to invasive treatment. These findings suggest that a good response to BT injection of the LES can identify an achalasia-variant form of EGJOO that will respond to LES muscle-directed invasive therapy.

Tumor thickness is associated with metastasis in patients with submucosal invasive adenocarcinoma of the esophagogastric junction.

In submucosal invasive adenocarcinoma of the esophagogastric junction (pT1b-SM AEG), the extent of tumor submucosal (SM) invasion is measured using the vertical depth of SM invasion with the muscularis mucosa. This study aimed to investigate whether tumor thickness and depth of invasion without accounting for muscularis mucosa were superior to the vertical depth of SM invasion as metastasis predictors. We enrolled patients with pT1b-SM AEG who underwent endoscopic resection or surgical resection (SR) at our institution between January 2011 and September 2019 and were followed up for ≥2years. The relationship between metastasis and clinicopathological factors was examined. Metastasis was defined as pathologically confirmed lymph node metastasis in the surgical specimen or recurrence during follow-up. This study included 57 patients (44 men; median age, 72years). Endoscopic resection and SR were performed in 16 and 41 patients, respectively. Nine patients were diagnosed with metastasis: five who underwent SR showed pathologically confirmed lymph node metastasis in the surgical specimens, and four experienced recurrences during a median follow-up of 48months. Univariate analyses showed that tumor thickness was significantly associated with metastasis (P = 0.021), and the vertical depth of SM invasion (P = 0.48) and depth of invasion (P = 0.38) were not. Furthermore, in multivariate analysis, tumor thickness ≥2800μm (odds ratio, 38.70; P = 0.013) was a significant predictor for metastasis. Tumor thickness may be a more convenient and useful predictor of metastasis in patients with pT1b-SM AEG than the vertical depth of SM invasion.

Sedation and Endoscopy-Assisted High-Resolution Manometry (SEA-HRM) in Patients Who Previously Failed Standard Esophageal Manometry

Objectives: Esophageal high-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, but it may be poorly tolerated and unsuccessful. We sought to evaluate a protocol for sedation and endoscopy-assisted (SEA) HRM in patients who previously failed standard HRM and assess patient perspectives towards it. Methods: Adult patients who previously failed HRM were prospectively enrolled. Under propofol sedation, an upper endoscopy was performed during which the HRM catheter was advanced under endoscopic visualization. If the catheter did not reach the stomach on its own, the endoscope itself or a snare was used to help it traverse the esophagogastric junction (EGJ). Results: Thirty patients participated (mean age 67.8, 70% female). The technical success of SEA-HRM was 100%. Twenty-two (73.3%) were diagnosed with a motility disorder including thirteen (43.3%) with achalasia. Eighteen (60%) had previously failed HRM due to discomfort/intolerance, while twelve (40%) failed due to catheter coiling in the esophagus. Subjects in the coiling group were more likely to need endoscopic assistance to traverse the EGJ (91.7% vs. 27.7%, p = 0.001) and have a motility disorder (100.0% vs. 55.6%, p = 0.010), including achalasia (75.0% vs. 22.2%, p = 0.004), compared to the discomfort/intolerance group. All patients preferred SEA-HRM and rated it higher than standard HRM (9.5 ± 1.3 vs. 1.9 ± 2.1, p = &lt;0.001, on a scale of 1–10). Conclusions: SEA-HRM is a highly successful and well-tolerated option in patients who previously failed standard HRM. This should be the recommended approach in cases of failed HRM rather than secondary tests of esophageal motility.

Distal contractile integral and other key predictors of mean nocturnal baseline impedance: The role of esophageal peristaltic vigor in mucosal permeability.

Understanding the relationship between distal contractile integral (DCI) and mean nocturnal baseline impedance (MNBI) could shed light on new diagnostic and treatment strategies, specifically concerning nocturnal reflux. This study aimed to assess this relationship to enhance our comprehension of the interplay between esophageal contractility and mucosal permeability. We identified adult patients who had high resolution esophageal manometry and pH-impedance tests performed within a 30-day period between December 2018 and March 2022. A random forest model was used to identify significant predictors of MNBI, assisting with variable selection for a following regression analysis. Subsequently, both univariable and multivariable regression models were utilized to measure the association between predictors and MNBI. Our study included 188 patients, primarily referred for testing due to reflux. The most common motility diagnoses were normal (62%) followed by possible esophagogastric junction outflow obstruction (22%). The mean DCI was 2020 mmHg∙s∙cm and MNBI was 3.05 kΩ. The random forest model identified 12 significant predictors for MNBI, key variables being acid exposure time (AET), total proximal reflux events, intraabdominal lower esophageal sphincter length, hiatal hernia presence, and DCI. Subsequent multivariable regression analyses demonstrated log AET (β = -0.69, p = <0.001), total proximal reflux events (β = -0.16, p = 0.008), hiatal hernia presence (β = -0.82, p = 0.014), log DCI (β = 1.26, p < 0.001), and age (β = -0.13, p = 0.036) as being significantly associated with MNBI. DCI is a key manometric predictor of MNBI emphasizing the role of manometry in detecting reflux risk and the need for its consideration in reflux management.

INTEGRATE IIa Phase III Study: Regorafenib for Refractory Advanced Gastric Cancer.

Treatment options for refractory advanced gastric and esophagogastric junction cancer (AGOC) are limited. Regorafenib, an oral multikinase inhibitor, prolonged progression-free survival (PFS) versus placebo in the INTEGRATE I phase II trial. INTEGRATE IIa was designed to examine whether regorafenib improved overall survival (OS). A double-blind placebo-controlled phase III trial compared regorafenib and best supportive care (BSC) versus placebo and BSC for participants with confirmed evaluable metastatic/advanced AGOC who failed ≥two prior therapies on a 2:1 random assignment, stratified by tumor location, geographic region (Asia v rest of world), and prior vascular endothelial growth factor inhibitors. The primary end point was OS. Treatment efficacy on OS was first tested in the pooled INTEGRATE I + INTEGRATE IIa cohort and, if significant, then in the INTEGRATE IIa cohort. Secondary end points were PFS, objective response rate, safety, and quality of life (QoL). INTEGRATE IIa enrolled 251 participants: 157 from Asia and 94 from rest of world and 169 received regorafenib and 82 received placebo. No significant heterogeneity was observed between INTEGRATE I and INTEGRATE IIa studies on OS. Pooled OS analysis hazard ratio (HR) was 0.70 (95% CI, 0.56 to 0.87; P = .001; 361 events). INTEGRATE IIa alone OS HR was 0.68 (95% CI, 0.52 to 0.90; P = .006; 238 events), the median OS was 4.5 months versus 4.0 months, and 12-month survival rates were 19% and 6%, for regorafenib versus placebo, respectively. After a preplanned adjustment for multiplicity, there were no statistically significant differences across regions or other prespecified subgroups. Regorafenib improved PFS (HR, 0.53 [95% CI, 0.40 to 0.70]; P < .0001) and delayed deterioration in global QoL (HR, 0.68 [95% CI, 0.52 to 0.89]; P = .0043). The toxicity profile was consistent with that of previous reports. Regorafenib improves survival compared with placebo in refractory AGOC.

Analysis of risk factors for intraoperative bleeding in patients with Siewert type II esophagogastric junction adenocarcinoma treated by two minimally invasive surgeries and its influence on prognosis: a retrospective study.

The present study aimed to analyze the independent risk factors for intraoperative bleeding in Siewert II adenocarcinoma of the esophagogastric junction (AEG) using two minimally invasive surgical approaches, namely, the laparoscopy-assisted abdominal trans-hiatal (LTH) method and transthoracic-laparoscopic esophagectomy (TLE). The clinical data of 100 patients with SiewertII AEG admitted to our hospital from October 2017 to October 2020 were retrospectively analyzed. According to the type of surgery, the patients were divided into LTH approach group and TLE approach group. The differences between the clinical characteristics of the patients in different groups and the differences in the intraoperative bleeding and prognosis between different surgical procedures were analyzed and compared using the t-test and chi-squared test. Multiple linear regression was used to identify the independent risk factors affecting the amount of intraoperative bleeding in patients. The results of this study showed that patients in the LTH group had significantly less intraoperative bleeding and operative time and significantly better postoperative recovery than the TLE group. The results of multivariate linear regression showed that the combined trans-thoracic-abdominal approach (P=0.000), advanced age (P=0.014), larger BMI (P=0.000), and larger tumor diameter (P=0.001) were the independent risk factors influencing the increase in intraoperative bleeding. In addition to the conventional factors that affect intraoperative bleeding, such as the patient's general condition, operation time, and tumor size, LTH surgery is another way to avoid intraoperative bleeding for Siewert type II AEG patients and can significantly improve postoperative recovery.

Adenocarcinoma of the esophagogastric junction: characteristics of female patients and young adult patients based on a 12-year retrospective and prospective multicenter clinicoepidemiological cohort study in Japan

BackgroundAdenocarcinoma of the esophagogastric junction (AEGJ) is most common in men and the elderly, but the disease is becoming more common in female and young adult persons. We have investigated the clinicoepidemiological characteristics of female and young adult patients with AEGJ and the 12-year trends in the Kurashiki area for young adult patients with AEGJ.MethodsPatients diagnosed with AEGJ in 12 hospitals between January 2008 and December 2019 were included in this study. Patients were divided into three groups by age (young adult [≤50 years], middle-aged [51 to 70 years], and elderly [>70 years]). Factors associated with AEGJ such as obesity, smoking, hiatal hernia and male, which were reported in our previous study, were identified.ResultsOne hundred and eighty-eight AEGJ patients, including 36 females and 20 young adults, were characterized. There was no significant change in the annual incidence of AEGJ among female (p=0.078) and young adult patients (p=0.89). Female patients without any associated factors, accounting for 53% (19/36) of the female patients and young adult patients, had significantly more histologically undifferentiated cancers than patients with at least one associated factor (58% [11/19] vs. 30% [50/169], p=0.025) and middle-aged and elderly patients (60% [12/20] vs. 30% [25/83] vs. 28% [24/85], p =0.026). Smoking was significantly less common in women than in men (8% [3/36] vs. 57% [87/152], p < 0.01). There were no significant differences between ages in the proportions of these associated factors.ConclusionsHistologically undifferentiated AEGJ cancers were more frequent in female patients without any associated factors and in young adult patients. Factors associated with AEGJ may differ between women and men, but they are similar in young adults and older adults. No increase in young adult patients with AEGJ was observed in the 12-year study.

S675 Esophagogastric Junction Outflow Obstruction: An Investigation of Ancillary Diagnostics Among Patients Meeting Manometric Criteria

S675 Esophagogastric Junction Outflow Obstruction: An Investigation of Ancillary Diagnostics Among Patients Meeting Manometric Criteria

Effect of hiatal hernia and esophagogastric junction morphology on esophageal motility: Evidence from high-resolution manometry studies.

High-resolution Manometry (HRM) is the most sensitive and specific test available for clinical assessment of hiatal hernia (HH), a common condition defined as the separation between the Lower Esophageal Sphincter (LES) and crural diaphragm (CD). While the link between HH and Gastroesophageal Reflux Disease (GERD) is established, the potential association of HH with esophageal dysmotility, independently from GERD, is uncertain. This study aimed to analyze if HH, with or without GERD, can associate with esophageal motility disorders. Consecutive patients without previous esophageal surgery who underwent HRM between 2018 and 2022 were enrolled. All patients with symptoms suggestive of GERD underwent impedance-pH testing off-therapy. HH was defined as a separation >1 cm between LES and CD, and esophagogastric junction (EGJ) morphology was classified as: Type I, when there was no separation between LES and CD; Type II, in case of minimal separation (>1 and <3 cm); Type III, when ≥3 cm of separation was present. Demographic and clinical characteristics were collected at baseline, including Age, Gender, Alcohol-, Coffee- and Smoke-habits, GERD diagnosis and symptoms' duration. Two cohorts of patients, with and without HH, were retrospectively individuated, and their association with Ineffective Peristalsis, Hypercontractile Esophagus and Outflow Obstruction was analyzed with univariate and multivariate Logistic regressions using the statistical software R. 848 consecutive patients were enrolled, and 295 cases of HH (34.8%), subdivided into 199 (23.5%) Type II- and 96 (11.3%) Type III-EGJ patients, were identified. Ineffective peristalsis was diagnosed in 162 (19.1%) subjects, Hypercontractile esophagus in 32 (3.8%), and Outflow Obstruction in 91 (10.7%), while GERD was present in 375 (44.2%) patients. HH was significantly associated with Ineffective Peristalsis (p < 0.001) and GERD (p < 0.001). Furthermore, HH resulted to be a risk factor for Ineffective peristalsis (OR 2.0, 95% CI 1.4-2.8, p < 0.001) both when the analysis was conducted in all the 848 subjects, independently from GERD, and when it was carried out in patients without GERD (OR 2.3, 95% CI 1.02-5.3, p = 0.04). The risk for Ineffective Peristalsis increased 1.3 times for every centimeter of HH. No statistically significant association was found between HH and Outflow obstruction or Hypercontractile Esophagus. An increasing separation between the LES and CD may lead to a gradual and significant elevation in the risk of Ineffective Peristalsis. Interestingly, this association with HH is true in patients with and in those without GERD, suggesting that the anatomical alteration seems to play a major role in motility change.

The history and use of the timed barium esophagram in achalasia, esophagogastric junction outflow obstruction, and esophageal strictures.

Dysphagia is one of the most common complaints that gastroenterologists encounter in the outpatient setting. To evaluate this common complaint, patients are often sent for a barium esophagram, a test that is widely available, inexpensive, and easy to perform. This simple test provides a reliable method to evaluate esophageal anatomy and structural abnormalities. This narrative reviews the history of the development and validation of the timed-barium esophagram (TBE), along with its strengths and limitations, and discusses its use in the pre- and posttreatment assessment of patients with achalasia, esophagogastric junction outflow obstruction (EGJOO), and esophageal strictures. Providing excellent anatomic detail of the esophagus and an accurate assessment of esophageal emptying, over time, the TBE has become part of the standard workup in our Swallowing Center for patients with dysphagia.

Systemic Therapy of Gastric Cancer—State of the Art and Future Perspectives

Background: The prognosis of patients diagnosed with locally advanced and metastatic gastric and esophago-gastric junction cancer is critical. The optimal choice of systemic therapy is essential to optimize survival outcomes. Methods: A comprehensive literature review via PubMed and analysis of major oncology congresses (European Society for Medical Oncology and American Society of Clinical Oncology websites) were conducted to ascertain the current status and latest developments in the systemic treatment of patients with localized or advanced gastric and esophago-gastric junction adenocarcinoma. Results: While neoadjuvant and perioperative chemotherapy for localized tumor stages is the preferred approach in the Western Hemisphere, adjuvant chemotherapy remains the preferred course of action in East Asia. The administration of chemotherapy, typically in the form of combinations comprising platinum and fluoropyrimidine compounds in combination with docetaxel, represents a standard of care. Investigations are underway into the potential of immunotherapy and other biologically targeted agents in the perioperative setting. To select the most appropriate therapy for advanced gastric cancer, including adenocarcinoma of the esophago-gastric junction, it is essential to determine biomarkers such as HER2 expression, PD-L1 combined positive score (CPS) (combined positive score), Claudin 18.2, and microsatellite instability (MSI). In the present clinical context, the standard first-line therapy is a combination of fluoropyrimidine and a platinum derivative. The selection of chemotherapy in combination with antibodies is contingent upon the specific biomarker under consideration. Conclusions: This article reviews the current state of the art based on recent clinical trial results and provides an outlook on the future of systemic therapy.

Spectrum aided vision enhancer enhances mucosal visualization by hyperspectral imaging in capsule endoscopy.

Narrow-band imaging (NBI) is more efficient in detecting early gastrointestinal cancer than white light imaging (WLI). NBI technology is available only in conventional endoscopy, but unavailable in magnetic-assisted capsule endoscopy (MACE) systems due to MACE's small size and obstacles in image processing issues. MACE is an easy, safe, and convenient tool for both patients and physicians to avoid the disadvantages of conventional endoscopy. Enabling NBI technology in MACE is mandatory. We developed a novel method to improve mucosal visualization using hyperspectral imaging (HSI) known as Spectrum Aided Visual Enhancer (SAVE, Transfer N,Hitspectra Intelligent Technology Co., Kaohsiung, Taiwan). The technique was developed by converting the WLI image captured by MACE to enhance SAVE images. The structural similarity index metric (SSIM) between the WLI MACE images and the enhanced SAVE images was 91%, while the entropy difference between the WLI MACE images and the enhanced SAVE images was only 0.47%. SAVE algorithm can identify the mucosal break on the esophagogastric junction in patients with gastroesophageal reflux disorder. We successfully developed a novel image-enhancing technique, SAVE, in the MACE system, showing close similarity to the NBI from the conventional endoscopy system. The future application of this novel technology in the MACE system can be promising.

Esophagogastric Junction Outflow Obstruction or Something More? Unveiling Esophageal Neuroendocrine Carcinoma.

Esophagogastric Junction Outflow Obstruction or Something More? Unveiling Esophageal Neuroendocrine Carcinoma.

Modified hepatic left lateral lobe inversion in laparoscopic proximal gastrectomy: An analysis of 13 cases.

In laparoscopic proximal gastrectomy (LPG), the prolapse of the hepatic left lateral lobe near the lesser curvature and esophageal hiatus can obstruct the field of vision and operation. Therefore, it is necessary to retract or obstruct the hepatic left lateral lobe to ensure a clear field of vision. To investigate the safety and clinical efficacy of the modified hepatic left lateral lobe inversion technique for LPG. A retrospective analysis was conducted on the clinical data of 13 consecutive patients with early-stage upper gastric adenocarcinoma or adenocarcinoma of the esophagogastric junction treated with LPG from January to December 2023 at the Department of Gastrointestinal Surgery, Second Affiliated Hospital of Fujian Medical University. The modified hepatic left lateral lobe inversion technique was used to expose the surgical field in all patients, and short-term outcomes were observed. In all 13 patients, the modified hepatic left lateral lobe inversion technique was successful during surgery without the need for re-retraction or alteration of the liver traction method. There were no instances of esophageal hiatus occlusion, eliminating the need for forceps to assist in exposure. There was no occurrence of intraoperative hepatic hemorrhage, hepatic vein injury, or hepatic congestion. No postoperative digestive complications of Clavien-Dindo grade ≥ II occurred within 30 days after surgery, except for a single case of pulmonary infection. Some patients experienced increases in alanine aminotransferase and aspartate aminotransferase levels on the first day after surgery, which significantly decreased by the third day and returned to normal by the seventh day after surgery. The modified hepatic left lateral lobe inversion technique has demonstrated satisfactory results, offering advantages in terms of facilitating surgical procedures, reducing surgical trauma, and protecting the liver.

Learning curve for a five-step procedure, transthoracic single-port assisted laparoscopic transabdominal diaphragmatic approach, for Siewert type II adenocarcinoma of the esophagogastric junction

Objective: To investigate the learning curve for a five-step procedure, namely, a transthoracic single-port assisted laparoscopic transabdominal diaphragmatic approach, for Siewert type II adenocarcinoma of the esophagogastric junction. Methods: In this retrospective cohort study, we analyzed relevant clinical data of 66 patients with Siewert type II adenocarcinoma of the esophagogastric junction who had undergone the five-step procedure performed by the same surgeon in the Gastrointestinal Surgery Department of Guangdong Provincial Hospital of Chinese Medicine from May 2017 to April 2023. The learning curve were plotted using cumulative summation analysis and selected indicators, including intraoperative blood loss, duration of surgery, time to first flatus, time to first tolerance of liquid food, length of hospital stay, and incidence of perioperative complications at different stages were compared. The data were analyzed using SPSS 24.0 statistical software. Numerical data are presented as cases (%) and data were analyzed using the χ2 test or Fisher's exact test. Normally distributed measurement data are presented as x±s, and independent sample t-testing was performed for inter group comparison. Non-normally distributed measurement data are presented as M(Q1, Q3) and the Mann-Whitney U test was used for inter group comparison. Results: The five-step procedure had been successfully completed without switching to open surgery in all 66 study patients. There were no perioperative deaths, blood loss was 100 (50, 200) mL and duration of surgery 329.4±87.3 minutes. The equation of optimal fit for the duration of surgery was y=0.031x3-4.4757x2+164.97x-264.4 (P<0.001, R2=0.9797). The cumulative summation learning curve reached a vertex when 25 surgical procedures had accumulated. Using 25 cases as the cut-off, we divided the learning curves into learning and proficiency periods and patients into learning (25) and proficiency period groups (41). There were no statistically significant differences between the two groups of patients in sex, age, body mass index, American Society of Anesthesiologists score, history of abdominal surgery, comorbidities, preoperative neoadjuvant therapy, maximum tumor diameter, surgical procedure, or T and N stage of tumor (P>0.05). The following factors differed significantly (all P<0.05) between the learning and proficiency stages: in the latter there was less intraoperative blood loss (100 [50, 100] ml vs. 200 [100, 200] ml, U=-3.940, P<0.001), shorter duration of surgery ([289.8±50.7] minutes vs. [394.4±96.0] minutes, t=5.034, P<0.001), more mediastinal lymph nodes removed (5 [2, 8] vs. 2 [1, 5], U=-2.518, P=0.012), earlier time to first flatus (2 [2, 3] days vs. 4 [3, 6] days, U=-4.016, P<0.001), earlier time to first tolerance of liquid food (5 [4, 6] days vs. 7 [6, 8] days, U=-2.922, P=0.003), shorter duration of hospital stay (8 [8, 10] vs. 10 [9, 12] days, U=-2.028, P=0.043). The incidence of surgical complications did not differ significantly between the two groups (P=0.238). Conclusion: Satisfactory results can be achieved with the five-step procedure for patients with Siewert type II adenocarcinoma of the esophagogastric junction once 25 procedures have been performed.

The impact of histological subtype on postoperative recurrence pattern and timing in locally advanced esophagogastric junction cancer

PurposeThe differences in tumor behavior between adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the esophagogastric junction (EGJ) have yet to be well investigated. The purpose of this study was to gain insights that can contribute to tailored treatments and follow-up strategies by analyzing the correlation between histological subtypes and oncological outcomes.MethodsA retrospective analysis was used to determine the characteristics of the histological subtypes of EGJ cancer by comparing the appearance of postoperative recurrence. A total of 102 consecutive patients with pathological stage IIA to IVA EGJ cancer, who underwent R0 surgery in our department from 2004 to 2020, were enrolled. The recurrence pattern, timing, survival, and potential prognostic factors were compared.ResultsAfter a median follow-up time of 70.1 months, the AC group demonstrated comparable lymph node failure-free survival (P = 0.291) and significantly worse non-lymphogenous recurrence-free survival (P = 0.035) than did the SCC group. A significantly longer period from surgery to recurrence was also observed in the AC group (P = 0.029). Multivariate analysis indicated that histological subtype (P = 0.015, 95% CI 1.24–7.28) was significantly correlated with the incidence of non-lymphogenous recurrence.ConclusionsThe pattern and timing of postoperative recurrence were significantly different between the histological subtypes of EGJ cancer. Compared with EGJ SCC, EGJ AC may have a greater tendency toward non-lymphogenous progression and a greater propensity for longer surgery-to-recurrence periods.