Siewert Type Research Articles

Marital Status Is a Prognostic Factor for Cardiovascular Mortality but Not a Prognostic Factor for Cancer Mortality in Siewert Type II Adenocarcinoma of the Esophagogastric Junction.

The impact of marital status on the prognosis of patients with Siewert type II adenocarcinoma of the esophagogatric junction (AEG) remained unclear. This study aimed to investigate the associations of marital status with cancer-specific death risk and cardiovascular death risk in Siewert type II AEG patients. Data for Siewert type II AEG patients were obtained from the Surveillance, Epidemiology, and End Results database from 2010 to 2015. A 1:1 propensity score matching (PSM) was applied to reduce inter-group bias between the married and unmarried groups. Kaplan-Meier analysis, a competing risk model and the Fine-Gray multivariable regression model were used to identify the prognostic value of marital status. In total, 1,623 subjects were included. After PSM, according to Fine-Gray multivariable regression analysis, there was no significant difference in the cumulative cancer-specific death rate between the married and the unmarried groups (hazard ratio (HR): 1.160, 95% confidence interval (CI): 0.994 - 1.354, P = 0.060). Patients in unmarried group had a higher cardiovascular death rate than patients in married group (HR: 3.066, 95% CI: 1.372 - 6.850, P = 0.006). Our study demonstrates that unmarried Siewert type II AEG patients are associated with higher cardiovascular death risk but not cancer-specific death risk compared with married patients.

Total laparoscopic total gastrectomy and distal esophagectomy combined with reconstruction by transhiatal esophagojejunal Roux-en-y mediastinal anastomosis for Siewert II AEG

PurposeThe optimal procedure is still controversial about Siewert type II AEG, We are attempt to explore the efficacy and feasibility of total laparoscopic total gastrectomy and distal esophagectomy combined with reconstruction by transhiatal esophagojejunal Roux-en-y mediastinal anastomosis for Siewert type II AEG.MethodData of patients with Siewert type II AEG who received total laparoscopic total gastrectomy and distal esophagectomy combined with reconstruction by transhiatal esophagojejunal Roux-en-y mediastinal anastomosis in the Hebei General Hospital were collected from October 2020 to October 2021, The operation time, surgical blood loss, the number of dissected lymph nodes, duration of drainage tube, the length of stay in ICU, the resume oral feeding time, the length of postoperative hospital stay, postoperative complications and other related indicators of the patients were collected to evaluate the safety and feasibility of this operation.ResultA total of 17 patients received total laparoscopic total gastrectomy and distal esophagectomy combined with reconstruction by transhiatal esophagojejunal Roux-en-y mediastinal anastomosisin the treatment of Siewert type II AEG were analyzed in our research. The mean operation time was 253 ± 24.8 min (196–347 min); The median surgical blood loss was 250 ml (20–2400 ml); The average number of dissected lymph nodes were 28 ± 4.6 (17–36); The median duration of drainage tube was 5 days (3–7days); The median length of stay in ICU was 18 h(10–34 h); The median time of resume oral feeding was 6 days (5–7days); The median postoperative hospital stay was 11 days (8–15 days). Among the all enrolled patients, one patient underwent the conversion to laparotomy due to the massive intraoperative bleeding, one patient developed anastomotic stenosis at jejunum side-to-side anastomosis on the first month after surgery, there was no case of death during the operation and postoperative anastomotic fistula. All patients achieved R0 resection with an average distance of 6 cm (4–8.5 cm) from the upper margin of the tumor to the resection margin.ConclusionThe operation of total laparoscopic total gastric and distal esophagectomy combined with reconstruction by transhiatal esophagojejunal Roux-en-y mediastinal anastomosis is technically feasible and sufficiently safe in the treatment of Seiwert type II AEG from our primary clinical experience. This procedure could be one of the alternatives for the radical treatment of Siewert type II AEG.

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

BackgroundWhether a transthoracic (TT) procedure by a thoracic surgeon or a transabdominal (TA) by a gastrointestinal surgeon is best for Siewert type II esophagogastric junction adenocarcinoma (EGJA) remains unknown. Survival and perioperative outcomes were compared between the two groups in this meta-analysis to clarify this argument.MethodsWe searched 7 databases for eligible studies comparing TT and TA procedures for Siewert type II EGJA. The final analyzed endpoints included intraoperative and hospitalization outcomes, recurrence, complication, and survival.ResultsSeventeen studies involving 10,756 patients met the inclusion criteria. The TA group had higher rates of overall survival (OS) (HR: 1.31 [1.20 ~ 1.44], p < 0.00001) and disease-free survival (DFS) (HR: 1.49 [1.24 ~ 1.79], p < 0.0001). The survival advantage of OSR and DFSR increased with time. Subgroup analysis of OS and DFS suggested that TA remained the preferred approach among all subgroups. More total/positive lymph nodes were retrieved, and fewer lymph node recurrences were found in the TA group. The analysis of perioperative outcomes revealed that the TA procedure was longer, had more intraoperative blood loss, and prolonged hospital stay. Similar R0 resection rates, as well as total recurrence, local recurrence, liver recurrence, peritoneal recurrence, lung recurrence, anastomosis recurrence and multiple recurrence rates, were found between the two groups. The safety analysis showed that the TT procedure led to more total complications, anastomotic leakages, cases of pneumonia, and cases of pleural effusion.ConclusionsThe TA procedure appeared to be a suitable choice for patients with Siewert type II EGJA because of its association with longer survival, fewer recurrences, and better safety.

OGC P08 Siewert type III gastro-oesophageal junction adenocarcinoma; total gastrectomy vs. oesophagectomy

Abstract Background Tumours of the gastro-oesophageal junction are amenable to different surgical resections. There is an increasing body of evidence to suggest Siewert type III tumours should be managed as gastric cancers and hence may be more appropriately resected via total gastrectomy. The aim of this study was to compare the outcomes of total gastrectomy and oesophagectomy in patients diagnosed with Siewert type III gastro-oesophageal junction (GOJ) adenocarcinoma. Methods Consecutive patients who underwent curative surgery [total gastrectomy (n=42) or oesophagectomy (n=35)] between 1 January 2010 – 03 April 2023 for Siewert type III GOJ adenocarcinoma were analysed prospectively [median age 68 years, (range 43-83 years), 76.6% male, neo-adjuvant treatment 74.0%]. The primary outcome measure was overall 5 and 10-year survival. Secondary outcomes included: 30- and 90-day mortality, lymph node harvest, positive node harvest, margin involvement, anastomotic leak and length of stay. Results Demographic details between both groups of patients were similar. Patients undergoing total gastrectomy had a significantly shorter length of hospital stay compared with patients undergoing oesophagectomy (median 8 vs. 10 days, p&amp;lt;0.006). Distal margin involvement was significantly higher in patients undergoing oesophagectomy (0% vs. 12.1 %, p=0.027). Overall, 5 and 10-year survival was significantly higher in patients undergoing total gastrectomy (62% and 52% vs. 36% and 22% respectively, p=0.013). There were no significant differences in lymph node harvest (median 29.5 vs. 33.0 nodes), anastomotic leak rates (2.4% vs. 11.4%), 30- (2.4% vs 0%) and 90-day (2.4% vs 2.9%) mortality. Conclusions Patients undergoing total gastrectomy have improved short and long-term outcomes compared with patients undergoing oesophagectomy for Siewert type III GOJ adenocarcinoma.

OGC V05 Robotic intrathoraxic linear stapled anastomosis following Ivor Lewis oesophagectomy

Abstract Background Ivor lewis oesophagectomy (ILO) for oesophageal cancer (OC) is associated with high morbidity with an anastomotic leak (AL) rate of upto 30% been quoted in literature. This can lead to return to intensive care, delayed recovery and mortality. Several techniques have been developed in an attempt to reduce this risk such as, hand sewn technique, circular anastomosis and side to side linear stapled anastomosis (LSA). Recent meta-analysis suggested reduced AL with LSA. We demonstrate our technique for a totally robotic side to side LSA performed for distal OC. Methods We detail the steps involved in the procedure, including trocar placement, necessary robotic instruments, and surgical description. 74 year old male patient with a BMI of 30 and performance status of 1, underwent robotic ILO for a Siewert type 1 T2N1 distal oesophageal adenocarcinoma after neo-adjuvant chemotherapy. Preoperatively staging investigations included endoscopy, endoscopic ultrasound, computerised tomography (CT) and positron emission tomography (PET). Fitness was assessed using cardio-pulmonary exercise testing (CPET). Results Patient was on the high dependency unit as per our routine practice for less than 24 hours and was transferred to our monitored ward bed. Enhanced recovery after surgery (ERAS) protocol was followed. There were no complications and patient was discharged in 8 days following ILO. Conclusions We demonstrate our technique using side to side LSA for robotic ILO.

Most Siewert type II esophagogastric junction adenocarcinomas in Chinese patients lack a Barrett esophagus background

The histological origins and classification of Siewert II esophageal gastric junction (EGJ) adenocarcinomas are controversial. While the American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) staging system suggests that they be classified as esophageal cancer, some scholars insist that these cancers include a Barrett esophageal (BE) adenocarcinoma form and a gastric adenocarcinoma form. To obtain data relevant to this debate, in this study, a multi-center sample of 25 cases of Siewert II EGJ adenocarcinoma spanning a 6-year period were analyzed. The endoscopic characteristics of the tumor lesions and pathology characteristics of peritumoral mucosal background in biopsies were determined. Cases were classified as esophageal adenocarcinoma if the tumor center was located on the oral side of the EGJ and accompanied by BE. They were classified as gastric adenocarcinoma if the tumor center was located on the anal side of the EGJ and accompanied by atrophic gastritis. Of the 25 cases examined, 20 had evaluable background mucosal data, including 14 (56 %) classified as gastric adenocarcinoma and 3 (12 %) classified as BE adenocarcinoma. The remaining 3 cases (12 %) did not have signs of BE or atrophic gastritis, and thus were not classified. Siewert type II EGJ adenocarcinoma cases in China were found to be heterogeneous, with most cases being consistent with gastric adenocarcinoma. Thus, it would not be reasonable to classify all Siewert type II EGJ adenocarcinomas as esophageal cancer.

A Novel Esophagogastrostomy Technique for Laparoscopic Proximal Gastrectomy: Conical Remnant Gastroesophageal Side-overlap Fundoplication.

There is currently no universally-accepted, ideal method of esophagogastric reconstruction to address reflux esophagitis and anastomotic complications of esophagogastrostomy after proximal gastrectomy. In June 2022, two patients with Siewert type II carcinoma of esophagogastric junction underwent laparoscopic proximal gastrectomies, using a novel esophagogastrostomy technique of Conical remnant GastroEsophageal side-Overlap fundoplication (CGEO). On postoperative day 4, upper gastrointestinal fluoroscopy was performed, with patients in downward and left oblique positions, allowing gastrografin to accumulate within fundic reconstructions. No reflux into the esophagus was subsequently observed, and both patients were discharged (postoperative days 9 and 11). Six months after surgery, endoscopic view showed that the reconstructed cardia returned to its normal state, in the absence of any reflux symptoms. As of April 2023, we have operated on four patients using CGEO, and all of them recovered without obvious reflux symptoms. CGEO is a feasible and safe reconstructive esophagogastrostomy procedure following laparoscopic proximal gastrectomy for Siewert type II esophagogastric junction carcinoma.

466. ESOPHAGECTOMY AFTER NEOADJUVANT CHEMORADIATION THERAPY: DOES THE TIMING OF SURGERY INFLUENCE THE OUTCOME?

Abstract Background Multimodality treatment, either neoadjuvant chemoradiotherapy (nCRT) or perioperative chemotherapy (e.g., FLOT), and surgery, represents the standard of care for locally advanced, resectable cancer of the esophagus and esophago-gastric junction. The recommended interval between the ending of nCRT and surgery is between 6 and 8 weeks. A prolonged time to surgery (TTS) is associated with an increase in pathologic complete response (pCR) and survival in different malignancies, with a possible increase in surgical difficulty and postoperative complications. Materials and methods: A retrospective analysis was conducted on 154 patients with cT2-4aN0-(+), cT1bN+, M0 squamous cell (SCC) and adenocarcinoma (AC) cancer of the esophagus and esophagogastric junction (Siewert type 1) treated with nCRT and surgery between August 2017 and January 2022. Three groups were identified: patients operated within 10 (n = 37), between 10 and 12 (n = 48) and beyond 12 weeks (n = 69). Minimum follow-up period was six months. Results Demographic and clinical characteristics were comparable. Mean length of stay was 13.1, 15.6 and 16.5 days (p = 0.06) respectively. Incidence of postoperative complications and their severity were not different between groups. No postoperative deaths were observed. No difference in pCR was found. When analyzed by histology, a slight increase was evident in patients with SCC (33.3%, 43.5%, 39.4%; vs ADC 16%, 16%, 16.7%), though not statistically significant. Similar results were obtained for tumor regression grade, with an increase in major responses for SCC over time (Mandard 1–2: SCC 50%, 61%, 62%; ADC 60%, 64%, 58%). No difference in overall survival was observed. Conclusions Esophagectomy performed more than 10 weeks after the end of chemoradiation therapy was not associated with an increase in postoperative morbidity. We observed, though, a trend towards longer hospital stays. The rate of major pathological response seems to increase over time after completion of chemoradiation therapy, but only for squamous histotype. Larger studies are required to corroborate these findings.

479. TRANSTHORACIC VERSUS TRANSABDOMINAL SURGICAL APPROACH FOR SIEWERT TYPE II ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMAS—A PROPENSITY SCORE-MATCHED ANALYSIS

Abstract Background Esophagogastric junctional(EGJ) adenocarcinoma is a complex type of cancer that varies in etiology and disease pattern depending on the tumor level. There is increasing evidence on the need for different surgical approaches for different Siewert types. The optimal surgical approach for Siewert type II cancer remains controversial. This study aims to compare the oncological and surgical safety of transthoracic and transabdominal approaches for type II cancers. Methods The study included patients who underwent resection for Siewert type II adenocarcinomas from 2003–2020 in a single tertiary center using transthoracic (TT) and transabdominal (TA) approaches with macroscopic tumor clearance. The TT approach referred to Lewis-Tanner esophagogastrectomy, while the TA approach included total gastrectomy and proximal gastrectomy. Data from a prospectively-managed database were analyzed to compare postoperative morbidity and mortality rates, lymph node harvest, completeness of resection and overall survival between the two groups. Propensity score matching (PSM) was used in further analyses. Results Excluding R2 resections, there were 54 patients in the TT and 45 (proximal gastrectomy:23) in the TA groups. cT stages were comparable. In TT group, median tumor length was 6 cm (vs. 3 cm,p = 0.000), 18.5% with esophageal extension of &amp;gt;4 cm above EGJ;75.9% had nodal metastases (vs. 47.7%, p = 0.004);20.4% underwent neoadjuvant therapy (vs. 6.8%, p = 0.057). Anastomotic leak and cardiopulmonary complication rates, R0 resection rates, nodal yield and positive lymph node ratios were comparable. Proximal margin was involved in 15.9% for TA (vs. 5.6%, p = 0.092). Overall median survival times were similar (TT vs. TA: 42vs.65 months, p = 0.557). PSM yielded 33 patients per group. Only one in TT group had &amp;gt;4 cm esophageal involvement. Cardiac complication rate in TT group was 23.6%(vs. 3.5%, p = 0.024). Conclusion After correcting for selection bias, positive lymph node ratio, resection margin and overall survival did not differ for the TT and TA approaches. Resection by the TT approach is associated with more cardiac complications. For Siewert type II tumors with limited thoracic esophageal extension, the TA approach is safe and should be sufficient.

46. THORACOSCOPIC REPAIR OF IATROGENIC INJURY TO THE THORACIC AORTA DURING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Description of video: Background We present the case of a 75-year-old male patient with locally advanced Siewert Type 2 gastroesophageal adenocarcinoma post neoadjuvant chemotherapy. Inadvertent through-and-through piercing of the lower thoracic aorta with the tip of an energy device just above the diaphragm was sustained during the thoracoscopic esophageal dissection phase of the three-field minimally-invasive McKeown approach. Methods The procedure proceed thoracoscopically. The lower thoracic aorta was dissected and mobilized proximally and distally, and clamped on both ends with the introduction of Debakey clamps directly through separate small incisions in the chest wall. Primary repair of both anterior and posterior defects was then performed with monofilament non-absorbable sutures. Total clamp time was 30 minutes (in 15-minute intervals). Results Post-repair, perfusion status to the distal viscera and lower limbs were verified and intact. The rest of the operation then proceeded uneventfully. A Computed Tomography scan of the thoracic aorta on postoperative day 14 showed a patent thoracic aorta with no intraluminal narrowing or thrombosis. Conclusion Thoracoscopic repair of aortic injury sustained during the thoracoscopic dissection phase of a minimally invasive esophagectomy can be performed safely in well-selected, haemodynamically stable patients. Drpbox link to video: https://www.dropbox.com/s/xbwt6ge23iywr3m/aorta3mus1.mp4?dl&amp;#x003D;0.

954 Oesophagectomy vs. Gastrectomy; a Type II Dilemma

Abstract Aim The optimal operation for Siewert type II cancers is unclear, with both oesophagectomy and total gastrectomy being undertaken. This study aimed to investigate the overall survival and associated operative outcomes of both approaches. Method A retrospective cohort study was performed of all Siewert type II Gastro-Oesophageal Junctional (GOJ) resections from a single oesophagogastric centralised service between 2010 and 2017. The primary outcome was 5-year overall survival (OS). Secondary outcomes were recurrence rate and operative morbidity. Results A total of 163 patients were included; 127 (77.9%) oesophagectomy vs. 36 (22.1%) gastrectomy. The 5-year OS for oesophagectomy vs. gastrectomy were 50.4% vs 41.7% with a median survival of 57 months vs. 31 months respectively (p = 0.062). No differences in the rate of recurrence (44.9% vs. 33.3%, p = 0.216) or overall rate of complications (63.8% vs. 63.9%, p = 0.990) were identified. Yet, significantly more major (Clavien-Dindo III+) complications occurred in the gastrectomy compared to the oesophagectomy cohort (38.9% vs. 20.5%, p = 0.012), driven partially by a higher anastomotic leak rate (19.4% vs 9.4%, p = 0.099). Cox regression revealed no significant difference in the 5-year OS between the two groups when accounting for confounders (HR 0.906, 95% CI 0.339-2.060, p = 0.814). Only age (HR 0.971, 95% CI 0.944-0.999, p = 0.046) and pT stage (HR 1.794, 95% CI 1.097-2.935, p = 0.020) were determinants of 5-year OS. Conclusions When accounting for confounders there were no significant differences in the overall survival based on the two approaches. Further multi-centre prospective studies would be advantageous to establish a consensus on the best approach.

184. INTRATHORACIC SIDE-OVERLAP ESOPHAGOGASTROSTOMY DURING MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract Backgrounds Surgical algorithm for esophagogastric junction cancer have been proposed according to the results of a recent prospective study. However, reconstruction method has yet to be standardized. Esophagogastrostomy is often performed for esophagogastric junction cancer with esophageal invasion, although, it has been related to frequent and severe complications. Recently, we have introduced IntraThoracic Side-overlap EsophagoGastrostomy (ITS-EG), an eazy and novel intrathoracic anastomotic method with reflux prevention mechanism during minimally invasive esophagectomy for esophagogastric junction cancer. Methods We retrospectively reviewed patient backgrounds and surgical/short term outcomes for the patient who underwent ITS-EG during minimally invasive esophagectomy for esophagogastric junction cancer between February 2018 to April 2023 at our institute. Results The study cohort included ten patients, with a median age of 67 (55–77) years. All tumors were classified as Siewert type II, and the median esophageal invasion length was 32 (11.8–40) cm. After extended proximal gastrectomy, patients underwent either thoracoscopic (five patients) or robot-assisted (five patients) minimally invasive esophagectomy followed by ITS-EG. ITS-EG consist of overlap anastomosis utilizing surgical stapler, and reflux prevention mechanism owing to the creation of pseudo-fornix and a slit-shaped anastomosis. The initial case suffered anastomotic leakage, however, recovered by conservative measures. All the other patients had an uneventful recovery without reflux esophagitis nor anastomotic stricture. Conclusion ITS-EG is an easy and safe esophagogastric anastomosis with reflux prevention mechanism during minimally invasive esophagectomy, and may be considered for esophagogastric junction cancers with esophageal invasion. Further accumulation of cases is needed to demonstrate the safety and efficacy of ITS-EG. Surgical procedure for ITS-EG would be presented by video.

Impact of the Surgical Approach for Neoadjuvantly Treated Gastroesophageal Junction Type II Tumors: A Multinational, High-volume Center Retrospective Cohort Analysis.

The aim of this study was to explore oncologic outcomes of transhiatal gastrectomy (THG) or transthoracic esophagectomy (TTE) for neoadjuvantly treated gastroesophageal junction (GEJ) Siewert type II adenocarcinomas, a multinational, high-volume center cohort analysis was undertaken. Neoadjuvant radiochemotherapy or perioperative chemotherapy (CTx) followed by surgery is the standard therapy for locally advanced GEJ. However, the optimal surgical approach for type II GEJ tumors remains unclear, as the decision is mainly based on individual experience and assessment of operative risk. A retrospective analysis of 5 prospectively maintained databases was conducted. Between 2012 and 2021, 800 patients fulfilled inclusion criteria for type II GEJ tumors and neoadjuvant radiochemotherapy or CTx. The primary endpoint was median overall survival (mOS). Propensity score matching was performed to minimize selection bias. Patients undergoing THG (n=163, 20.4%) had higher American Society of Anesthesiologists (ASA) classification and cT stage ( P <0.001) than patients undergoing TTE (n=637, 79.6%). Neoadjuvant therapy was different as the THG group were mainly undergoing CTx (87.1%, P <0.001). The TTE group showed higher tumor regression ( P =0.009), lower ypT/ypM categories (both P <0.001), higher nodal yield ( P =0.009) and higher R0 resection rate ( P =0.001). The mOS after TTE was longer (78.0 vs 40.0 months, P =0.013). After propensity score matching a higher R0 resection rate ( P =0.004) and mOS benefit after TTE remained ( P =0.04). Subgroup analyses of patients without distant metastasis ( P =0.037) and patients only after neoadjuvant chemotherapy ( P =0.021) confirmed the survival benefit of TTE. TTE was an independent predictor of longer survival. Awaiting results of the randomized CARDIA trial, TTE should in high-volume centers be considered the preferred approach due to favorable oncologic outcomes.

Histological study of the structural layers around the esophagus in the lower mediastinum.

In Japan, the transhiatal approach, including lower mediastinal lymph node dissection, is widely performed for Siewert type II esophagogastric junction adenocarcinoma. This procedure is generally performed in a magnified view using laparoscopy or a robotic system, therefore, the microanatomy of the lower mediastinum is important. However, mediastinal microanatomy is still unclear and classification of lower mediastinal lymph nodes is not currently based on fascia or other microanatomical structures. To clarify the fascia and layer structures of the lower mediastinum and classify the lower mediastinal tissue. We dissected the esophagus and surrounding organs en-bloc from seven cadavers fixed in 10% formalin. Organs and tissues were then cut at the level of the lower thoracic esophagus, embedded in paraffin, and serially sectioned. Tissue sections were stained with Hematoxylin-Eosin (all cadavers) and immunostained for the lymphatic endothelial marker D2-40 (three cadavers). We observed the periesophageal fasciae and layers, and defined lymph node boundaries based on the fasciae. Lymphatic vessels around the esophagus were observed on immunostained tissue sections. We identified two fasciae, A and B. We then classified lower mediastinal tissue into three areas, paraesophageal, paraaortic, and intermediate, using these fasciae as boundaries. Lymph nodes were found to be present and were counted in each area. The dorsal part of the intermediate area was thicker on the caudal side than on the cranial side in all cadavers. On the dorsal side, no blood vessels penetrated the fasciae in six of the seven cadavers, whereas the proper esophageal artery penetrated fascia B in one cadaver. D2-40 immunostaining showed lymphatic vessel connections between the paraesophageal and intermediate areas on the lateral and ventral sides of the esophagus, but no lymphatic connection between areas on the dorsal side of the esophagus. Histological studies identified two fasciae surrounding the esophagus in the lower mediastinum and the layers separated by these fasciae were used to classify the lower mediastinal tissues.

A novel trans hiatal esophago-gastrostomy with anti-reflux triangle-valve for laparoscope assisted lower esophagectomy and proximal gastrectomy for Siewert type II/III adenocarcinoma of the esophagogastric junction: a three-year retrospective cohort study

A novel trans hiatal esophago-gastrostomy with anti-reflux triangle-valve for laparoscope assisted lower esophagectomy and proximal gastrectomy for Siewert type II/III adenocarcinoma of the esophagogastric junction: a three-year retrospective cohort study

Accurate Preoperative Evaluation of the Location of Esophagogastric Junction Adenocarcinoma Using Positron Emission Tomography-Computed Tomography.

The surgical procedure for esophagogastric junction (EGJ) adenocarcinoma usually depends on the location of its epicenter or proximal margin, but accurate evaluation of these positions is often difficult. The usefulness of positron emission tomography-computed tomography (PET-CT) for this purpose is unknown. Between June 2005 and February 2015, we enrolled 30 patients with cT2-4 EGJ adenocarcinoma (Siewert type I/II) who underwent surgical resection. We ascertained the sensitivity and specificity of preoperative PET-CT for identifying the primary tumor and regional lymph node metastasis, and compared PET-CT and pathological findings in terms of the distance from the EGJ to the tumor epicenter or proximal tumor margin. PET-CT detected the primary tumor with a sensitivity of 97% (29/30), and detected lymph node metastasis with a sensitivity and specificity of 22% (4/18) and 100% (8/8), respectively. No significant association was observed between the maximal standardized uptake value and histological type, tumor size, or pT status. Regarding the accuracy of evaluating tumor location, the median differences between PET-CT and pathological measurements were .6cm for the tumor epicenter and .5cm for the proximal margin from the EGJ. PET-CT and pathological findings showed agreement regarding Siewert classification type (I or II) and lengths of esophageal involvement exceeding 4cm or 2cm in 77% (10/13), 85% (11/13), and 85% (11/13) of cases, respectively. PET-CT had high sensitivity for primary EGJ adenocarcinoma. It may effectively locate the tumor epicenter and proximal margin and thus help clinicians determine the optimal surgical procedure.

Utility of robotic surgery for Siewert type II/III adenocarcinoma of esophagogastric junction: transhiatal robotic versus laparoscopic approach

BackgroundRobotic surgery (RS) has been rapidly adopted for gastric cancer and adenocarcinoma of the esophagogastric junction (AEG). However, the utility of RS for Siewert type II/III AEG remains unclear.MethodsForty-one patients who underwent either transhiatal RS (n = 15) or laparoscopic surgery (LS) (n = 26) for Siewert type II/III AEG were enrolled in this study. The surgical outcomes of the two groups were compared.ResultsIn the entire cohort, there were no significant intergroup differences in the operative time, blood loss volume, or number of retrieved lymph nodes. The length of the postoperative hospital stay was shorter in the RS group than in the LS group (14.20 ± 7.10 days vs. 18.73 ± 17.82 days, respectively; p = 0.0388). The morbidity rate (Clavien–Dindo grade ≥ 2) was similar between the groups. In the Siewert II cohort, there were no significant intergroup differences in short-term outcomes. In the entire cohort, there was no significant difference between the RS and LS groups in the 3-year overall survival rate (91.67% vs. 91.48%, N.S.) or 3-year disease-free survival rate (91.67% vs. 91.78%, N.S.), respectively. Likewise, in the Siewert type II cohort, there was no significant difference between the RS and LS groups in the 3-year overall survival rate (80.00% vs. 93.33%, N.S.) or 3-year disease-free survival rate (80.00% vs. 94.12%, N.S.), respectively.ConclusionsTranshiatal RS for Siewert II/III AEG was safe and contributed to similar short-term and long-term outcomes compared with LS.

Relevance of Subcarinal Lymph Node Dissection for Gastroesophageal Junction Adenocarcinoma

IntroductionReported rates of subcarinal lymph node (LN) metastases for esophageal carcinoma vary from 20% to 25% and the relevance of subcarinal lymph node dissection (LND) for gastroesophageal junction (GEJ) adenocarcinoma is poorly defined. This study aimed to evaluate rates of subcarinal LN metastasis in GEJ carcinoma and determine their prognostic significance. MethodsPatients with GEJ adenocarcinoma undergoing robotic minimally invasive esophagectomy from 2019 to 2021 were retrospectively assessed within a prospectively maintained database. Baseline characteristics and outcomes were examined with attention to subcarinal LND and LN metastases. ResultsAmong 53 consecutive patients, the median age was 62, 83.0% were male, and all had Siewert type I/II tumors (49.1% and 50.9%, respectively). Most patients (79.2%) received neoadjuvant therapy. Three patients had subcarinal LN metastases (5.7%) and all had Siewert type I tumors. Two had clinical evidence of LN metastases preoperatively and all three additionally had non-subcarinal nodal disease. A greater proportion of patients with subcarinal LN disease had more advanced (T3) tumors compared to patients without subcarinal metastases (100.0% versus 26.0%; P = 0.025). No patient with subcarinal nodal metastases remained disease free at 3 y after surgery. ConclusionsIn this consecutive series of patients with GEJ adenocarcinoma undergoing minimally invasive esophagectomy, subcarinal LN metastases were found only in patients with type I tumors and were noted in just 5.7% of patients, which is lower than historical controls. Subcarinal nodal disease was associated with more advanced primary tumors. Further study is warranted to determine the relevance of routine subcarinal LND, especially for type 2 tumors.

Feasibility of a single-port thoracoscopy-assisted five-step laparoscopic procedure via transabdominal diaphragmatic approach for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma

Objective: We aimed to explore the feasibility of a single-port thoracoscopy- assisted five-step laparoscopic procedure via transabdominal diaphragmatic(TD) approach(abbreviated as five-step maneuver) for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma (AEG). Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) age 18-80 years; (2) diagnosis of Siewert type II AEG; (3) clinical tumor stage cT2-4aNanyM0; (4) meeting indications of the transthoracic single-port assisted laparoscopic five-step procedure incorporating lower mediastinal lymph node dissection via a TD approach; (5) Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1; and (6) American Society of Anesthesiologists classification I, II, or III. The exclusion criteria included previous esophageal or gastric surgery, other cancers within the previous 5 years, pregnancy or lactation, and serious medical conditions. We retrospectively collected and analyzed the clinical data of 17 patients (age [mean ± SD], [63.6±11.9] years; and 12 men) who met the inclusion criteria in the Guangdong Provincial Hospital of Chinese Medicine from January 2022 to September 2022. No.111 lymphadenectomy was performed using five-step maneuver as follows: superior to the diaphragm, starting caudad to the pericardium, along the direction of the cardio-phrenic angle and ending at the upper part of the cardio-phrenic angle, right to the right pleura and left to the fibrous pericardium , completely exposing the cardio-phrenic angle. The primary outcome includes the numbers of harvested and of positive No.111 lymph nodes. Results: Seventeen patients (3 proximal gastrectomy and 14 total gastrectomy) had undergone the five-step maneuver including lower mediastinal lymphadenectomy without conversion to laparotomy or thoracotomy and all had achieved R0 resection with no perioperative deaths. The total operative time was (268.2±32.9) minutes, and the lower mediastinal lymph node dissection time was (34.0±6.0) minutes. The median estimated blood loss was 50 (20-350) ml. A median of 7 (2-17) mediastinal lymph nodes and 2(0-6) No. 111 lymph nodes were harvested. No. 111 lymph node metastasis was identified in 1 patient. The time to first flatus occurred 3 (2-4) days postoperatively and thoracic drainage was used for 7 (4-15) days. The median postoperative hospital stay was 9 (6-16) days. One patient had a chylous fistula that resolved with conservative treatment. No serious complications occurred in any patient. Conclusion: The single-port thoracoscopy-assisted five-step laparoscopic procedure via a TD approach can facilitate No. 111 lymphadenectomy with few complications.

Thoracoscopic laparoscopy-assisted Ivor-Lewis resection of esophagogastric junction cancer

Objective: To investigate the outcome of patients with esophagogastric junction cancer undergoing thoracoscopic laparoscopy-assisted Ivor-Lewis resection. Methods: Eighty-four patients who were diagnosed with esophagogastric junction cancer and underwent Ivor-Lewis resection assisted by thoracoscopic laparoscopy at the National Cancer Center from October 2019 to April 2022 were collected. The neoadjuvant treatment mode, surgical safety and clinicopathological characteristics were analyzed. Results: Siewert type Ⅱ (92.8%) and adenocarcinoma (95.2%) were predominant in the cases. A total of 2 774 lymph nodes were dissected in 84 patients. The average number was 33 per case, and the median was 31. Lymph node metastasis was found in 45 patients, and the lymph node metastasis rate was 53.6% (45/84). The total number of lymph node metastasis was 294, and the degree of lymph node metastasis was 10.6%(294/2 774). Among them, abdominal lymph nodes (100%, 45/45) were more likely to metastasize than thoracic lymph nodes (13.3%, 6/45). Sixty-eight patients received neoadjuvant therapy before surgery, and nine patients achieved pathological complete remission (pCR) (13.2%, 9/68). Eighty-three patients had negative surgical margins and underwent R0 resection (98.8%, 83/84). One patient, the intraoperative frozen pathology suggested resection margin was negative, while vascular tumor thrombus was seen on the postoperative pathological margin, R1 resection was performed (1.2%, 1/84). The average operation time of the 84 patients was 234.5 (199.3, 275.0) minutes, and the intraoperative blood loss was 90 (80, 100) ml. One case of intraoperative blood transfusion, one case of postoperative transfer to ICU ward, two cases of postoperative anastomotic leakage, one case of pleural effusion requiring catheter drainage, one case of small intestinal hernia with 12mm poke hole, no postoperative intestinal obstruction, chyle leakage and other complications were observed. The number of deaths within 30 days after surgery was 0. Number of lymph nodes dissection, operation duration, and intraoperative blood loss were not related to whether neoadjuvant therapy was performed (P>0.05). Preoperative neoadjuvant chemotherapy combined with radiotherapy or immunotherapy was not related to whether postoperative pathology achieved pCR (P>0.05). Conclusion: Laparoscopic-assisted Ivor-Lewis surgery for esophagogastric junction cancer has a low incidence of intraoperative and postoperative complications, high safety, wide range of lymph node dissection, and sufficient margin length, which is worthy of clinical promotion.