Surgical treatment of adenocarcinoma of the esophago-gastric junction

Abstract

Cancer of the esophagogastric junction (EGJ) is gaining importance, both in the West and in the East. Cancers around the EGJ are most commonly classified into Siewert types (5cm proximal and distal to EGJ). The Japanese classification is much more focused, to an area just 2cm proximal and distal to the EGJ, and assigns tumors according to whether they are esophageal or gastric-predominant in their locations. There isn’t much controversy with regards to type I and III cancers. For the former, a transthoracic esophagectomy with mediastinal nodal dissection is generally performed. For type III cancers, a total radical gastrectomy is performed. The Dutch trial comparing transhiatal vs. transthoracic resection for type I and II cancers concluded that for type I cancers with limited nodal metastases, a transthoracic approach imparted survival advantage. Type II cancers are most problematic. There are advocates of both total radical gastrectomy with lower mediastinal dissection as well as a two-field Ivor Lewis esophagogastrectomy. In Japan, results from Japanese Oncology Group Trial 9502 suggests that for Siewert type II and III cancers with 3 cm or less of esophageal involvement, a total transabdominal approach with lower mediastinal nodal dissection will give equivalent survival compared with a left thoraco-abdominal approach, but with less postoperative morbidities. Prophylactic lymph node dissection around the distal stomach for EGJ cancers is unlikely to benefit. Total gastrectomy is commonly performed more for the reason of expected impaired quality-of-life with a direct esophagogastrostomy in the abdomen. More novel techniques such as double-tract reconstruction after proximal gastrectomy and anti-reflux anastomosis are less commonly performed. In the author's experience, factors that may lead to preference of a transthoracic approach include bulky EGJ tumors, suspected mediastinal lymph node, unhealthy esophageal remnant especially post-chemotherapy (+/-RT), difficult exposure at the hiatus, and adequate distal stomach for reconstruction. On the contrary, patients with earlier-stage tumor, healthy esophageal remnant, good exposure at the hiatus, elderly patients may favor an abdominal approach. Whether a total gastrectomy or proximal gastrectomy should be performed primarily depends on tumor stage. In choosing the various approaches, an upper GI surgeon cognizant with both esophageal and gastric surgery is best equipped to deal with EGJ tumors.