Influence of the surgical technique on survival in the treatment of carcinomas of the true cardia (Siewert Type II) - Right thoracoabdominal vs. transhiatal-abdominal approach

A retrospective analysis of lymph node dissection in Siewert II adenocarcinoma of the esophagogastric junction

BACKGROUND

Analyze the pattern of lymph node metastasis in Siewert II adenocarcinoma of the esophagogastric junction (AEG) and provide a basis for the principles of surgical access.

METHODS

The clinical data of 112 Siewert type II AEG patients admitted to the Fifth Department of Thoracic Surgery, the Fourth Hospital of Hebei Medical University from 2020 to 2022 were retrospectively collected. The probability of lymph node metastasis in each site and the clearance rate of lymph nodes in each site by different surgical approaches were analyzed.

RESULTS

The lymph node metastasis rates in the middle and upper mediastinum group, the lower mediastinum group, the upper perigastric + supra pancreatic group, and the lower perigastric + hepatoduodenal group were 0.0%, 5.4%, 61.6%, and 17.1%, (P < 0.001). The number of lymph nodes cleared in the middle and upper mediastinum group was 0.00, 0.00, 4.00 in the transabdominal approach (TA), left thoracic approach (LT), and Ivor-Lewis (IL) group, (P < 0.001); The number of lymph nodes cleared in the lower mediastinal group was 0.00, 2.00, 2.00, (P < 0.001); The number of lymph node dissection in the perigastric + hepatoduodenal group was 3.00, 0.00, and 8.00, (P < 0.001). The overall complication rates were 25.7%, 12.5%, and 36.4%, (P = 0.058).

CONCLUSION

Siewert II AEG has the highest rate of lymph node metastasis in the upper perigastric + supra-pancreatic region, followed by the lower perigastric + hepatoduodenal, lower mediastinal, middle, and upper mediastinal regions. Ivor-Lewis can be used for both thoracic and abdominal lymph node dissection and does not increase the incidence of postoperative complications.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

INTRODUCTION

To date, the discussion is still ongoing whether the Siewert II adenocarcinoma of the esophagogastric junction (AEG) should be resected either by thoracoabdominal esophagectomy or gastrectomy with resection of the distal esophagus by transhiatal extension. The aim of our study was to compare the oncological and perioperative outcomes of the transthoracic approach (TTA) and the transabdominal approach (TAA).

METHODS

Searches of electronic databases identifying studies from Cochrane, PubMed and Google Scholar were performed. Randomised and non-randomised studies comparing TTA and TAA approaches for surgical treatment of AEG Siewert type II were included. The Newcastle-Ottawa and Jada scales were used to evaluate methodological quality. The risk of bias was assessed using the Rob v2 and Robins-I tools. Meta-analyses were conducted for the outcomes.

RESULTS

We included 17 trials (2 randomised controlled trials and 15 cohorts) involving 15297 patients. Longer three-year overall survival, five-year overall survival and R0 resection rates were observed in the TTA group. However, TTA had greater morbidity and pulmonary complications.

CONCLUSION

Transthoracic approach appears to be preferable for selected Siewert II tumours. This may lead to higher survival rates and better R0 resection rate. Well-designed studies are needed to confirm the results of this systematic review.

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

BACKGROUND

Whether 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.

METHODS

We 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.

RESULTS

Seventeen 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.

CONCLUSIONS

The 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.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Surgical Treatment of Siewert II Gastroesophagel Junction Adenocarcinoma: Esophagectomy or Gastrectomy? Review

Introduction. Surgery is the only curative treatment option for patients with gastroesophageal junction (GEJ) adenocarcinoma. These tumors can be resected by gastrectomy or esophagectomy depending on tumor localization. Although, both surgeries are available for Siewert type II GEJ cancer, it remains unknown which one is superior. This review summarizes current evidences on the optimal surgical approach for Siewert type II GEJ adenocarcinoma. Methods. The literature search was performed within the PubMed database and 9 stu­dies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma were included. The outcomes of interest included: length of surgery, numbers of retrieved lymph nodes, resection margins, postoperative morbidity and mortality, hospitalization time, 5-year overall, and disease-free survival rates. Results. Current studies do not favor any type of surgery in terms of length of the surgery, R0 resection rate, or postoperative morbidity. There is some tendency towards higher anastomotic leakage and postoperative surgical site infections rate after gastrectomy, while a higher incidence of pneumonia after esophagectomy. Similar, available studies suggest, that esophagectomy may lead to improved long-term outcomes. Conclusions. There is a lack of high-quality studies comparing gastrectomy and esophagectomy for Siewert type II GEJ adenocarcinoma. Esophagectomy may lead to improved long-term outcomes, but this preliminary data has to be confirmed in large, randomized control trials.

Comparison of Efficacy Between Transabdominal and Transthoracic Surgical Approaches for Siewert Type II Adenocarcinoma of the Esophagogastric Junction: A Systematic Review and Meta-Analysis

Background

The optimal surgical approach, whether transabdominal (TA) or transthoracic (TT), for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) remains controversial. This study compares the efficacy of TA and TT surgical approaches for Siewert type II AEG.

Methods

Studies comparing the surgical and oncological outcomes of TA and TT surgical approaches for Siewert type II AEG up to June 2021 were systematically searched on the Web of Science, PubMed, Embase, and Cochrane Library. A pooled analysis was performed for the available data regarding the baseline features, surgical, and oncological outcomes. The RevMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted.

Results

Twelve studies with a total of 2,011 patients, including 985 patients in the TA group and 1,026 patients in the TT group, were included in this study. In the pooled analysis, the surgical outcomes, namely, operative time (MD = −54.61, 95% CI = −123.76 to 14.54, P = 0.12), intraoperative blood loss (MD = −28.85, 95% CI = −71.15 to 13.46, P = 0.18), the number of dissected lymph nodes (MD = 1.90, 95% CI = −1.32 to 5.12, P = 0.25), postoperative complications (OR = 0.84, 95% CI = 0.65 to 1.07, p = 0.16), anastomotic leakage rate (OR = 1.02, 95% CI = 0.63 to 1.65, p = 0.93), and postoperative death rate (OR = 0.89, 95% CI = 0.46 to 1.72, p = 0.73), and the oncological outcomes, namely, overall recurrence rate (OR = 0.75, 95% CI = 0.37 to 1.50, p = 0.41), 3-year overall survival (OS) rate (OR = 1.19, 95% CI = 0.54 to 2.65, p = 0.66), and 5-year OS rate (OR = 1.21, 95% CI = 0.84 to 1.74, p = 0.30) of the two groups were all comparable.

Conclusions

Both TA and TT surgical approaches are appropriate for Siewert type II AEG, and neither has a significant advantage in terms of short- and long-term outcomes. However, more high-quality randomized controlled trials are needed to confirm this conclusion.

The abdominal-transhiatal surgical approach versus the thoracoabdominal surgical approach in Siewert type II adenocarcinoma of the esophagogastric junction: protocol for a multicenter prospective, open, parallel, and randomized controlled trial

Background

To date, Siewert type II adenocarcinoma of the esophagogastric junction (ST-II AEG) can be removed radically utilizing either the abdominal-transhiatal (TH) or the right thoracoabdominal (RTA) approaches. Because of a paucity of high-quality direct evidence, the appropriate surgical approach for ST-II AEG remains debatable. In the present, only several retrospective studies are available, representing ambiguous results. Thus, prospective randomized clinical trials are demanded to compare the survival, oncological outcomes, safety and efficiency and life quality between the TH and RTA approach in patients with resectable AEG of Siewert type II.

Methods

A prospective, multicenter, open, randomized, and parallel controlled study named S2AEG will be conducted. Three hundred and twelve patients who match the inclusion criteria but not the exclusion criteria will be participating in the trial and randomly divided into the TH (156) and RTA (156) cohorts. The primary efficacy endpoint is the 3-year disease-free survival (DFS) following the operation. The rate of R0-resection, the number and site of lymph nodes infiltrated and dissected, postoperative complications, hospital days and life quality are the second endpoints.

Discussion

This study is the first prospectively randomized controlled trial aiming to compare the surgical outcomes between TH and RTA approaches in patients with resectable ST-II AEG. It is hypothesized that patients in the TH cohort would harvest equivalent oncological results and survival while maintaining acceptable life quality when compared to patients in the RTA cohort. Our findings will provide high-level clinical evidence for clinical decision-making on the appropriate surgical approach for patients with ST-II AEG. Embarked in November 2019, this research will be completed 3 years after the final participant’s enrolment date.

Trial registration

Clinical Trial.gov ID: NCT04910789 May 29, 2021. Name: S2AEG.

Short-Term and Long-Term Outcomes Following Transhiatal versus Right Thoracoabdominal Resection of Siewert Type II Adenocarcinoma of the Esophagogastric Junction

Background

Few studies have evaluated the outcomes of transhiatal and right thoracoabdominal resection of Siewert type II adenocarcinoma of the esophagogastric junction. This study investigated the relative effect of these two methods in the surgical treatment of Siewert type II adenocarcinoma of the esophagogastric junction.

Methods

Clinical data for 211 Siewert type II cancer patients were collected and classified into transhiatal group (n = 181) and right thoracoabdominal group (n = 30) according to surgical approach. Short-term outcomes were compared between these two groups. A 1:1 propensity score matching was performed using a logistic regression model. Recurrence-free survival and overall survival were compared between the matched groups.

Results

The right thoracoabdominal group had significantly greater intraoperative blood loss and longer operative time compared with transhiatal group. Complications corresponding to Clavien–Dindo grade III or higher were 4.4% in transhiatal group and 30% in right thoracoabdominal group (P < 0.05). The right thoracoabdominal group exhibited greater blood loss, longer operative time, longer hospitalization, and a smaller number of lymph nodes retrieved than the transhiatal group as evidenced by PSM analysis, and patients in transhiatal group also experienced significantly better survival than patients in right thoracoabdominal group.

Conclusion

In this study, the transhiatal approach was associated with more favorable short-term and oncological outcomes than the right thoracoabdominal group approach for Siewert type II adenocarcinoma of the esophagogastric junction. The transhiatal approach with total gastrectomy appears to be an optional choice for this type of tumor, especially for esophagus invasion ≤2 cm. Well-designed randomized control trials are necessary to validate our findings.

Transhiatal versus transthoracic surgical approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

With the increasing prevalence of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (EGJ), the optimal surgical treatment is not universally agreed. This meta-analysis compares the safety and efficacy between the transhiahtal (TH) approach and the transthoracic (TT) approach.

METHODS

A systematic and electronic search of several databases was performed up to June 2020. The Newcastle-Ottawa scale was used to evaluate article quality and funnel plots were created to identify potential publication bias. The random-effects model was used when significant heterogeneity was identified.

RESULTS

In total, nine retrospective studies and two randomized controlled trials (RCTs) involving 2331 patients were included. Decreased intraoperative blood loss, shorter hospital stay, lower incidence of pulmonary complications, and longer 3-year overall survival were observed in the TH group. There were no significant differences concerning duration of surgery, R0 resection rate, number of dissected lymph nodes, perioperative mortality and morbidity rate, abdominal complication rate, or anastomotic leak rate. With regard to 5-year overall survival, a potential benefit may be achieved with the TH approach, which requires further confirmation.

CONCLUSION

In terms of surgery-related and long-term outcomes, the TH approach may be more appropriate for Siewert type Ⅱ adenocarcinoma of EGJ, especially for esophagus invasion ≤4 cm.

Distribution of lymph node metastases in locally advanced adenocarcinomas of the esophagogastric junction (cT2-4): comparison between Siewert type I and selected Siewert type II tumors

INTRODUCTION

The distribution of lymph node metastases in locally advanced Siewert type I and type II AEG (adenocarcinoma of the esophagogastric junction) remains unclear. The diversity of data in the literature reflects the non-uniformity of tumor stages and surgical procedures in previous studies.

MATERIALS AND METHODS

Based on a retrospective analysis from our single-center database, we examined distributions of lymph node metastases in types I and II cT2-4 AEG. The dataset comprised 44 patients; 19 and 25 patients had type I and type II, respectively. All patients underwent subtotal esophagectomy and total mediastinal lymphadenectomy, which included dissection of the upper mediastinal lymph nodes. The histological data of the surgical specimens were analyzed to evaluate metastasis rates in each lymph node station according to the Japanese Esophageal Society (JES) and American Joint Committee on Cancer (AJCC) guidelines.

RESULTS

Lymph node metastases were observed in 75.0% cases (n = 33/44). There was no significant difference in the total lymph node metastasis rate between the two groups (type I 73.7% versus type II 76.0%). On comparing each lymph node region separately, no statistically significant differences were noted between the groups: upper mediastinal (type I 31.6% versus type II 24.0%), middle and lower mediastinal (type I 31.6% versus type II 44.0%), paragastric (type I 61.1% versus type II 76.0%), and celiac lymph nodes (type I 16.7% versus type II 25.0%).

CONCLUSION

In advanced clinical stages, the metastasis rate is high at all mediastinal lymph node regions in both type I and type II AEGs.

Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer

PURPOSE

We retrospectively investigated the risk factors for mediastinal lymph node (MLN) metastasis in esophagogastric junction (EGJ) cancer with an epicenter within 2 cm above and below the anatomical cardia, including both adenocarcinoma (AC) and squamous cell carcinoma (SCC).

METHODS

Fifty patients who underwent initial surgery for EGJ cancer from January 2002 to December 2013 were included in this study. We defined metastatic lymph nodes as pathological metastases in resected specimens and recurrence within 2 years postoperatively.

RESULTS

Thirty-four patients had AC and 16 had SCC; 24 patients underwent transhiatal resection and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of the histological type, 9 of whom had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20 mm. In addition, 10/13 patients had stage pN2-3 cancer. Multivariable analysis identified EIL ≥ 20 mm and stage pN2-3 as significant risk factors for MLN metastasis. The 5-year overall survival was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2-3, and not the presence of MLN metastasis, was a significantly poor prognostic factor.

CONCLUSION

MLN metastasis in EGJ cancer may have a close association with the EIL of the tumor, but the presence of MLN metastasis itself was not a poor prognostic factor. The significance and indications for MLN dissection should be clarified in prospective clinical trials.