Should gastric cardia cancers be treated with esophagectomy or total gastrectomy? A comprehensive analysis of 4,996 NSQIP/SEER patients

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.

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.

Transthoracic esophagectomy compared to transhiatal extended gastrectomy for adenocarcinoma of the esophagogastric junction: a multicenter retrospective cohort study

Optimal surgical treatment for Siewert type II esophagogastric junction adenocarcinoma is debated. The aim of this study was to compare transhiatal extended gastrectomy (TEG) and transthoracic esophagectomy (TTE). Patients with Siewert type II tumors who underwent a resection by TEG or TTE in two centers (Erasmus University Medical Center, Rotterdam, and University of Verona) between 2014 and 2019 were identified. To limit selection bias, patients were matched for baseline characteristics and compared with a multivariable logistic regression model. Some 159 patients treated by TEG (60 patients, 37.7%) or TTE (99 patients, 62.3%) were included. Patients in the TEG group were older, had less tumor invasion of the esophagus, and were more often excluded from neoadjuvant therapy. Post-operative morbidity was comparable (P = 0.88), while 90-day mortality was higher after TEG (90-day mortality 10.0% in TEG group vs. 2.0% in TTE group P = 0.01). R0 resection was achieved in 83.3% of patients after TEG and in 97.9% after TTE (P < 0.01), with the proximal resection margin involved in 16.6% of patients after TEG versus 0 in TTE group (P < 0.01). The 3-year overall survival was comparable (TEG: 36.5%, TTE: 48.4%, P = 0.12). At multivariable analysis, (y)pT category was an independent risk factor for 3-year recurrence. After matching, TEG was still associated with an increased risk of incomplete tumor resection (P = 0.03) and proximal margin involvement (P < 0.01), while there were no differences in post-operative morbidity (P = 0.56) and mortality (P = 0.31). Our data suggest that patients with Siewert type II tumors treated by TEG are exposed to a higher risk of positive proximal resection margin compared to TTE.

Evidence-based approach to the treatment of esophagogastric junction tumors

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

Consolidation Therapy in Esophageal Cancer

Consolidation therapy describes dose intensification strategies or additional treatment performed following completion of the primary regimen. In the case of esophageal cancer, this applies to cases of potentially persistent disease after definitive multi-modality therapy, including surgery. Consolidation should also be considered for patients initially planned to undergo surgery after neoadjuvant therapy, but for any reason elected a nonoperative strategy during treatment. With the advent of targeted therapy and immunotherapy, additional options may be available for consolidation in the future.

Minimally invasive total adventitial resection of the cardia for tumours of the oesophagogastric junction

PURPOSE

A cohort study analysing phases and outcomes of the learning curve required to master minimally invasive total adventitial resection of the cardia.

METHODS

Data from 198 consecutive oesophagectomies performed by a single surgeon was collected prospectively. Patients' stratification reflected chronologically and technically the four main phases of the learning curve: open surgery (open total adventitial resection of the cardia (TARC), n = 45), hybrid Ivor Lewis oesophagectomy (HILO, n = 50), laparoscopic-thoracoscopic assisted (LTA, n = 56) and totally minimally invasive TARC (TMI TARC, n = 47). Operating time, hospital stay, specimen lymph nodes and resection margins were analysed. Five-year survival was the main long-term outcome measured.

RESULTS

Overall 5-year survival was 45%. Perioperative mortality was 1.5% (n = 3). Hospital stay was 22 ± 23 days. Specimen lymph node median was 20 (range: 15-26). Resection margins were negative (R = 0, American College of Pathologists) in 193 cases (97.4%). Five-year survival in the four phases was 37.8%, 44.9%, 42.9% and 55.3%, showing a positive trend towards the end of the learning curve (p = 0.024). Median specimen lymph nodes was 20 (range: 15-22) for open TARC, 18.5 (13-25) for HILO, 19.5 (15-25) for LTA and 23 (18-30) for TMI TARC (p = 0.006). TMI TARC, adenocarcinoma, R >0, T >2, N >0 and LyRa (ratio positive/total specimen nodes) were associated with survival on univariate analysis. T >2 and LyRa independently predicted worse survival on multivariate analysis. CUSUM analysis showed surgical proficiency gain since laparoscopy was introduced.

CONCLUSION

Mastering minimally invasive TARC requires a long learning curve. TMI TARC is safe and oncologically appropriate and may benefit long-term survival: it should be validated by randomised trials as a standardised anatomical resection for tumours of the oesophagogastric junction.

Treatment Patterns for Gastroesophageal Junction Adenocarcinoma in the United States

Despite the increasing incidence of gastroesophageal junction adenocarcinoma (GEJA), the optimal treatment strategy for the disease remains unknown. The objective of this study was to describe treatment patterns for GEJA in the United States. The National Cancer Database was searched to identify all patients who underwent resection of the lower esophagus, abdominal esophagus, and/or gastric cardia for GEJA between 2006 and 2016. Patients were grouped by clinical disease stage: early localized (L; T1-2N0), locally advanced (LA; T3-4N0), regional (R; T1-2N+), or regionally advanced (RA; T3-4N+). The search identified 28,852 GEJA patients. The dominant age range was 60–69 years (39%). Most patients were men (85%), and most were white (92%). Most L patients (69%) underwent upfront surgery, whereas most LA, R, and RA patients received neoadjuvant therapy (NAT; 86%, 80%, and 90%, respectively). Among patients who received NAT, 85% received chemoradiotherapy. Adjuvant therapy was relatively uncommon across all groups (15–20%). In the LA, R, and RA groups, overall survival was greater in patients who received NAT compared to upfront surgery (p < 0.001). With the exception of patients with early localized node-negative disease, most GEJA patients receive neoadjuvant chemoradiotherapy despite the lack of prospective trials reporting survival benefit over chemotherapy alone.

Totally mechanical linear stapled anastomosis for minimally invasive Ivor Lewis esophagectomy: Operative technique and short-term outcomes

BACKGROUND

Anastomosis is one of the important factors affecting anastomotic complications after esophagectomy, and multiple reports have compared anastomotic complications among various techniques. However, there is insufficient evidence in the literature to definitively recommend one anastomotic technique over another.

METHOD

We retrospectively evaluated 34 consecutive patients who underwent an improved totally mechanical side-to-side: posterior-to-posterior linear stapled (TM-STS) technique for minimally invasive Ivor Lewis esophagogastric anastomosis, performed by a single surgeon between February 2015 to November 2017. The operative techniques and short-term outcomes are analyzed in this study.

RESULTS

There were no conversions to an open approach and a complete resection was achieved in all patients undergoing this improved procedure. During the first half of the series, the median operation time was 355 minutes, ranging from 257 to 480 minutes. Over the second half of this series, the median operation time was reduced to 256 minutes. There were no mortalities or serious postoperative complications. Only one patient (2.9%) had an anastomotic leak, which resolved without intervention. Another patient (2.9%) experienced transient, delayed conduit emptying which upper gastrointestinal radiography determined was due to a mechanical obstruction caused by an abnormally long gastric tube in the chest cavity.

CONCLUSIONS

The results of our study suggest that this improved TM-STS technique is safe and effective for minimally invasive Ivor Lewis esophagectomy, and can be considered as one of the alternative procedure for patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma.

Proximal Gastrectomy versus Total Gastrectomy for Siewert Type II Adenocarcinoma of the Esophagogastric Junction: A Comprehensive Analysis of Data from the SEER Registry

Background

To determine the ideal surgical approach (total gastrectomy (TG) vs. proximal gastrectomy (PG)) for Siewert type II adenocarcinoma of the esophagogastric junction (AEG), we searched and analyzed the Surveillance, Epidemiology, and End Results (SEER) data.

Methods

Patients with Siewert type II AEG treated by TG or PG were identified from the 2004–2014 SEER dataset. We obtained the patients' overall survival (OS) and cancer-specific survival (CSS) and stratified the patients by surgical approach. We performed a propensity score 1 : 1 matching (PSM) analysis and a univariate and multivariate Cox proportional hazards model.

Results

A total of 2,217 patients with 6th AJCC stage IA–IIIB Siewert type II AEG was examined: 1,584 patients (71.4%) underwent PG, and 633 patients (28.6%) underwent TG. The follow-up time was 1–131 months. OS favored total gastrectomy before the PSM analysis (χ² = 3.952, p = 0.047), but after this analysis, there was no significant difference between TG and PG (χ² = 2.227, p = 0.136). The univariate and multivariate analyses identified age as an independent factor, and an X-tail analysis revealed 70 years as a cut-off point. The patients aged ≥ 70 years obtained a significant long-term OS benefit from PG compared to TG (χ² = 8.245, p = 0.004), and those aged < 70 years showed no difference between TG and PG (χ² = 0.167, p = 0.682).

Conclusions

PG showed an equivalent survival benefit to TG in both the early and locally advanced stages of Siewert type II AEG. For elderly patients, PG is strongly recommended because of its clearer OS benefit compared to TG.

For Gastroesophageal Junction Cancers, Does an "Esophageal" or "Gastric" Surgical Approach Offer Better Perioperative and Oncologic Outcomes?

BACKGROUND

The optimal surgical approach to the resection of gastoesophageal junction cancer is unknown. A comprehensive literature search was conducted to further compare the esophageal and gastric approaches to gastroesophageal junction cancer.

METHODS

A systematic review of the literature from January 1990 to May 2018 was performed to determine whether an esophageal or gastric surgical approach offers better perioperative and oncologic outcomes.

RESULTS

A total of 179 abstracts were identified and after excluding publications for non-English language, primary focus on neoadjuvant and/or adjuvant treatment, lack of comparison of surgical approaches or not addressing morbidity, mortality, or survival-related outcomes, a total of 14 nonrandomized, comparative studies were reviewed in detail.

CONCLUSIONS

The proximal and distant extent of the tumor based on Siewert type classification greatly influences choice of operation. Overall survival rates and surgical outcomes are comparable, and surgical approach should be dictated by patient factors.

Adenocarcinoma of the oesophagogastric junction Siewert II: An oesophageal cancer better cured with total gastrectomy

INTRODUCTION

Type II AEG is now considered as oesophageal cancer in the seventh and eighth edition of TNM classification but optimal surgical approach for these tumors remains debated. The objective of the study is to assess and compare surgical and oncological outcomes of two surgical approaches: superior polar oesogastrectomy (SPO) or total gastrectomy (TG) in patients with type II adenocarcinoma of the oesophagogastric junction (AEG).

MATERIAL AND METHODS

183 patients with type II AEG treated from 1997 to 2010 in 21 French centers by SPO or TG were included in a multicenter retrospective study. The surgical and oncological outcomes were compared between these two surgical approaches.

RESULTS

A TG was performed in 64 (35%) patients whereas 119 (65%) patients were treated by SPO with transthoracic approach in 100 of them (83.2%) and transhiatal approach with cervicotomy in 19 (16.8%). Surgical outcomes were comparable between the two approaches with a postoperative mortality rate of 4.9% and a severe operative morbidity rate within 30 days of 15.3%. Median survival in patients operated on by TG was of 46 months compared to 27 months in patients treated by SPO (p = 0.118). At multivariate analysis, TG appears to be an independent good prognostic factor compared to SPO (HR = 1.847; p = 0.008). However, TG was also associated with a higher rate of incomplete resection, (12.5% vs 5.9%; p = 0.120).

CONCLUSION

When TG allows obtaining tumor-free resection margins, this approach should be preferred to SPO.

Surgical principles for optimal treatment of esophagogastric junction adenocarcinoma

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing worldwide. Management of these tumors remains controversial given their unique location between the esophagus and the stomach. Debate surrounding the optimal therapy for EGJ adenocarcinoma has often centered around the tumor origin as defined by the Siewert classification system. However, the optimal surgical management should focus on adhering to important surgical principles that will allow for the best outcomes and prognosis regardless of tumor location including resection with appropriate and negative histological margins, adequate lymphadenectomy, minimization of morbidity and mortality, and preservation of quality-of-life. In this article, we provide a discussion of the controversy surrounding EGJ adenocarcinoma within the framework of these concepts.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

Results of the different surgical options for the treatment of cancer of the esophagogastric junction: Review of the evidence

There is significant controversy in the management of cardiac cancer. It seems unanimous that Siewert type I tumors be operated on as cancer of the esophagus and Siewert type III as gastric cancer. However, for "true" cancer of the gastric cardia or Siewert II, the authors do not agree. There is the obvious need for free proximal and distal margins, as well as correct lymphadenectomy. For some, esophagectomy is necessary to perform correct radical oncological surgery, but other authors defend that an abdominal approach is sufficient to perform total gastrectomy and distal esophagectomy. Recent and older papers published do not clarify this issue, and their results are contradictory. Chemotherapy prior to surgery can reduce the size of the tumor and the presence of lymphadenopathies.

Optimal Extent of Transhiatal Gastrectomy and Lymphadenectomy for the Stomach-Predominant Adenocarcinoma of Esophagogastric Junction: Retrospective Single-Institution Study in China

Background: The optimal extent of gastrectomy and lymphadenectomy for esophagogastric junction (EGJ) cancer is controversial. Our study aimed to compare the long-term survival of transhiatal proximal gastrectomy with extended periproximal lymphadenectomy (THPG with EPL) and transhiatal total gastrectomy with complete perigastric lymphadenectomy (THTG with CPL) for patients with the stomach-predominant EGJ cancer.

Methods: Between January 2004, and August 2015, 306 patients with Siewert II tumors were divided into the THTG group (n = 148) and the THPG group (n = 158). Their long-term survival was compared according to Nishi's classification. The Kaplan–Meier method and Cox proportional hazards models were used for survival analysis.

Results: There were no significant differences between the two groups in the distribution of age, gender, tumor size or Nishi's type (P > 0.05). However, a significant difference was observed in terms of pathological tumor stage (P < 0.05). The 5-year overall survival rates were 62.0% in the THPG group and 59.5% in the THTG group. The hazard ratio for death was 0.455 (95% CI, 0.337 to 0.613; log-rank P < 0.001). Type GE/E = G showed a worse prognosis compared with Type G (P < 0.05). Subgroup analysis stratified by Nishi's classification, Stage IA-IIB and IIIA, and tumor size ≤ 30 mm indicated significant survival advantages for the THPG group (P < 0.05). However, this analysis failed to show a survival benefit in Stage IIIB (P > 0.05).

Conclusions: Nishi's classification is an effective method to clarify the subdivision of Siewert II tumors with a diameter ≤ 40 mm above or below the EGJ. THPG with EPL is an optimal procedure for the patients with the stomach-predominant EGJ tumors ≤30 mm in diameter and in Stage IA-IIIA. For more advanced and larger EGJ tumors, further studies are required to confirm the necessity of THTG with CPL.

Gastrectomy compared to oesophagectomy for Siewert II and III gastro-oesophageal junctional cancer in relation to resection margins, lymphadenectomy and survival

It is unclear whether gastrectomy or oesophagectomy offer better outcomes for gastro-oesophageal junction (GOJ) cancer. A total of 240 patients undergoing total gastrectomy (n = 85) or oesophagectomy (n = 155) for Siewert II-III GOJ adenocarcinoma were identified from a Swedish prospective population-based nationwide cohort. The surgical approaches were compared in relation to non-radical resection margins (main outcome) using multivariable logistic regression, providing odds ratios (ORs) and 95% confidence intervals (CIs), mean number of removed lymph nodes with standard deviation (SD) using ANCOVA, assessing mean differences and 95% CIs, and 5-year mortality using Cox regression estimating hazard ratios (HRs) and 95% CIs. The models were adjusted for age, sex, comorbidity, tumour stage, and surgeon volume. The non-radical resection rate was 15% for gastrectomy and 14% for oesophagectomy, and the adjusted OR was 1.61 (95% CI 0.68-3.83). The mean number of lymph nodes removed was 14.2 (SD ± 9.6) for gastrectomy and 14.2 (SD ± 10.4) for oesophagectomy, with adjusted mean difference of 2.4 (95% CI-0.2-5.0). The 5-year mortality was 76% following gastrectomy and 75% following oesophagectomy, with adjusted HR = 1.07 (95% CI 0.78-1.47). Gastrectomy and oesophagectomy for Siewert II or III GOJ cancer seem comparable regarding tumour-free resection margins, lymph nodes removal, and 5-year survival.

[Differentiated surgical approach for adenocarcinoma of the gastroesophageal junction]

For adenocarcinoma of the gastroesophageal junction (GEJ) the classification of Siewert with its three subtypes is well established as a practical approach to surgical treatment. Transthoracic esophagectomy with gastric tube formation is generally accepted as the surgical standard for adenocarcinoma of the distal esophagus (GEJ type I). Intrathoracic esophagogastrostomy has become the most frequently used anastomotic technique (Ivor Lewis esophagectomy). Both the abdominal and thoracic part can be safely performed with a minimally invasive access. For subcardiac gastric cancer (GEJ type III) transhiatal extended gastrectomy is the resection of choice. For true cardiac carcinomas (GEJ type II) it has not yet been decided which of the abovementioned surgical procedures offers the best long-term survival. If technically possible in terms of a complete resection, transhiatal extended gastrectomy should be preferred because of a better postoperative quality of life. For GEJ type II tumors a minimally invasive approach is not recommended if the extent of resection cannot be safely determined preoperatively.

Surgical approaches to adenocarcinoma of the gastroesophageal junction: the Siewert II conundrum

BACKGROUND

The Siewert classification system for gastroesophageal junction adenocarcinoma has provided morphological and topographical information to help guide surgical decision-making. Evidence has shown that Siewert I and III tumors are distinct entities with differing epidemiologic and histologic characteristics and distinct patterns of disease progression, requiring different treatment. Siewert II tumors share some of the characteristics of type I and III lesions, and the surgical approach is not universally agreed upon. Appropriate surgical options include transthoracic esophagogastrectomy, transhiatal esophagectomy, and transabdominal extended total gastrectomy.

PURPOSE

A review of the available evidence of the surgical management of Siewert II tumors is presented.

CONCLUSIONS

Careful review of the data appear to support the fact that a satisfactory oncologic resection can be achieved via a transabdominal extended total gastrectomy with a slight advantage in terms of perioperative complications, and overall postoperative quality of life. Overall and disease-free survival compares favorably to the transthoracic approach. These results can be achieved with careful selection of patients balancing more than just the Siewert type in the decision-making but considering also preoperative T and N stages, histological type (diffuse type requiring longer margins that are not always achievable via gastrectomy), and the presence of Barrett's esophagus.

Oesophageal cancer

Oesophageal cancer is the sixth most common cause of cancer-related death worldwide and is therefore a major global health challenge. The two major subtypes of oesophageal cancer are oesophageal squamous cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC), which are epidemiologically and biologically distinct. OSCC accounts for 90% of all cases of oesophageal cancer globally and is highly prevalent in the East, East Africa and South America. OAC is more common in developed countries than in developing countries. Preneoplastic lesions are identifiable for both OSCC and OAC; these are frequently amenable to endoscopic ablative therapies. Most patients with oesophageal cancer require extensive treatment, including chemotherapy, chemoradiotherapy and/or surgical resection. Patients with advanced or metastatic oesophageal cancer are treated with palliative chemotherapy; those who are human epidermal growth factor receptor 2 (HER2)-positive may also benefit from trastuzumab treatment. Immuno-oncology therapies have also shown promising early results in OSCC and OAC. In this Primer, we review state-of-the-art knowledge on the biology and treatment of oesophageal cancer, including screening, endoscopic ablative therapies and emerging molecular targets, and we discuss best practices in chemotherapy, chemoradiotherapy, surgery and the maintenance of patient quality of life.

Failure to operate on resectable gastric cancer: implications for policy changes and regionalization

BACKGROUND

A significant proportion of patients never receive curative-intent surgery for resectable gastric cancer (GC). The primary aims of this study were to identify disparities and targetable risk factors associated with failure to operate in the context of national trends in surgical rates for resectable GC.

METHODS

The National Cancer Database was used to identify patients with resectable GC (adenocarcinoma, clinical stage IA-IIIC, 2004-2013). Multivariate modeling was used to identify predictors of resection and to analyze the impact of surgery on overall survival (OS).

RESULTS

Of 46,970 patients with resectable GC, 18,085 (39%) did not receive an appropriate operation. Among unresected patients, 69% had no comorbidities. Failure to resect was associated with reduced median OS (44.4 versus 11.8 mo, hazard ratio [HR]: 2.09, P < 0.001). In the multivariate analysis, the most critical factors affecting OS were resection (HR: 2.09) and stage (reference IA; HR range: 1.16-3.50, stage IB-IIIC). Variables independently associated with no surgery included insurance other than private or Medicare (odds ratio [OR]: 1.60/1.54), nonacademic/nonresearch hospital (OR: 1.16), non-Asian race (OR: 1.72), male (OR: 1.19), older age (OR: 1.04), Charlson-Deyo score >1 (OR: 1.17), residing in areas with median income <$48,000 (OR: 1.23), small urban populations <20,000 (OR: 1.41), and stage (reference IA; OR range: 1.36-3.79, stage IB-IIIC, P < 0.001).

CONCLUSIONS

Over one-third of patients with resectable GC fail to receive surgery. Suitable insurance coverage and treatment facility are the most salient (and only modifiable) risk factors for omitting surgery. To mitigate national disparities in surgical care, policymakers should consider improving insurance coverage in underserved areas and regionalization of gastric cancer care.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: A retrospective study of 3 surgical procedures

The present study was aimed to investigate the application of right thansthoracic Ivor-Lewis (IL), left transthoracic (LTT), and left thoracoabdominal (LTA) approach in Siewert type II adenocarcinoma of esophagogastric junction (AEG).The data of 196 patients with Siewert type II AEG received surgical resection in our cancer center between January 2014 and April 2016 was retrospectively analyzed. Finally, 136 patients met the inclusion criteria were enrolled in the study and divided into the IL (47 cases), LTT (51 cases), and LTA group (38 cases). Clinical and short-term treatment effects were compared among the 3 groups.The patients with weight loss, diabetes, and heart disease increased in the LTT group (P = 0.054, P = 0.075, and P = 0.063, respectively). Operation time was significantly longest in the IL group (P < 0.001), but the amount of bleeding and tumor size did not significantly differ among the 3 groups (P = 0.176 and P = 0.228, respectively). The IL group had the significantly longest proximal surgical margin (P < 0.001) and most number of total (P < 0.001) and thoracic lymph nodes (P < 0.001) dissected. Both the IL and LTA groups had more abdominal lymph nodes dissected than the LTT group (P < 0.001). In general, the IL and LTT groups had the highest dissection rates of every station of thoracic (P < 0.05) and lower mediastinal lymph nodes (P < 0.05), respectively. The dissection rate of the paracardial, left gastric artery, and gastric lesser curvature lymph nodes did not differ significantly among the 3 groups (P > 0.05), but the dissection rate of the hepatic artery, splenic artery, and celiac trunk lymph nodes was significantly highest in the IL group (P < 0.05). Postoperative hospital stay, perioperative complications, and mortality did not differ significantly among the 3 groups (P > 0.05).Compared with the traditional left transthoracic approach, the Ivor-Lewis approach did not increase the perioperative mortality and complication rates in Siewert type II AEG, but obtained satisfactory length of the proximal surgical margin, and was better than the left transthoracic approach in thoracic and abdominal lymph node dissection. However, the advantages of Ivor-Lewis procedure requires further follow-up and validation through prospective randomized controlled trials.

The surgical management of esophago-gastric junctional cancer

The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.

What's the Best Way to Treat GE Junction Tumors? Approach Like Gastric Cancer

The debate as to the optimal classification, staging, and treatment of gastroesophageal junction (GEJ) tumors wages on, and one must acknowledge that there is no "one-size-fits-all" approach. However, in this review we are charged with defending the position that all GEJ tumors are best treated like gastric cancer. We submit that, as stated, this is not a defensible position and that a clear definition of terms is warranted. Given the rarity of squamous cell carcinoma and the dramatic rise in incidence of adenocarcinoma of the GEJ in the West, we define GEJ "tumors" to mean adenocarcinomas of the GEJ. Furthermore, on the basis of their location, pathogenesis, and biologic behavior, we submit that few would argue with the contention that Siewert type I GEJ tumors are best treated like distal esophageal cancer and that Siewert type III GEJ tumors are best treated like gastric cancer. The real debate concerns the management of Siewert type II GEJ tumors, which arise immediately at the esophagogastric junction. Thus, for the purposes of this review, we have taken the liberty of redefining the question as what's the best way to treat adenocarcinomas of the true GEJ (i.e., Siewert type II tumors), and we submit that these tumors are in fact best treated like gastric cancer. This approach ensures that patients receive those therapies needed for the locoregional and systemic control of their disease together with a surgical procedure that optimizes complete tumor and regional lymph node resection while limiting morbidity.

Thoracoscopic side-to-side esophagogastrostomy by use of linear stapler-a simplified technique facilitating a minimally invasive Ivor-Lewis operation

PURPOSE

Minimally invasive esophagectomy (MIE) has been met with increased interest for the surgical treatment of esophageal cancer. One critical obstacle for the implementation of MIE has been the intrathoracic anastomosis. In this study, we describe a technique of thoracoscopic intrathoracic anastomosis using a linear stapler in prone position and present the short-term outcomes of this procedure.

METHODS

This prospective pilot study included 46 consecutive patients with a cancer either of the gastroesophageal junction (GEJ) or the distal esophagus who underwent either total MIE or thoracoscopic-assisted esophagectomy followed by intrathoracic stapled side-to-side anastomosis. The short-term outcomes including postoperative complications were recorded and analyzed.

RESULTS

This pilot study included 41 males (89 %) and 5 females (11 %) with a mean age of 65.7 years. The majority had adenocarcinoma (93 %). Before surgery, 4 patients (8.7 %) had an incomplete endoscopic submucosal resection, 5 patients (11 %) received chemotherapy alone, and 33 patients (71 %) had chemoradiotherapy. Mean operation time was 408 minutes. Postoperative complications classified as Clavien-Dindo Grade IIIa or more severe occurred in 7 patients (15 %), of whom 4 patients (8.7 %) developed anastomotic leakages without any need for intensive care. Another 2 patients (4.3 %) required intensive care due to aspiration pneumonia and acute renal failure. No in-hospital mortality was registered. Only one patient (2.2 %) with anastomotic leakage developed postoperative anastomotic stenosis requiring balloon dilatation.

CONCLUSIONS

The intrathoracic stapled side-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.

Defining the Impact of Surgical Approach on Perioperative Outcomes for Patients with Gastric Cardia Malignancy

BACKGROUND

Gastric cardia cancer is currently treated with several operations. The purpose of the current study was to compare outcomes associated with three common operative approaches.

METHODS

The ACS-NSQIP Participant Use File was searched to identify all patients with gastric cardia malignancy who underwent total gastrectomy (TG), transhiatal esophagectomy (THE), or thoraco-abdominal esophagectomy (TAE) between 2005 and 2012. Demographic, perioperative risk factors, and outcomes were analyzed.

RESULTS

Overall, there were 982 patients identified in the database who met inclusion criteria. The median age was 65 years (range 20-88) and 807 (82.2%) were male. The number of patients allocated to each approach was 204 TGs (20.8%), 271 THE (27.6%), and 507 TAE (51.6%). All approaches had similar major morbidity, cardiopulmonary morbidity, and 30-day mortality, however, TAE was associated with the highest overall morbidity (TAE 49.9% vs. TG 40.7% and THE 43.5%, p = 0.048). The independent risk factors predicting mortality were age greater than 65 years, history of myocardial infarction, and postoperative cardiopulmonary morbidity.

CONCLUSIONS

For patients with proximal gastric cancer, the three most common operative approaches were associated with clinically-significant rates of overall and major morbidity. Approach-associated morbidity should be considered along with tumor location and extent when choosing a technique for resection of gastric cardia malignancy.

Comprehensive geriatric assessment in patients with gastric and gastroesophageal adenocarcinoma undergoing gastrectomy

OBJECTIVE

The purpose of this study was to identify clinical and geriatric assessment variables associated with outcome in patients with gastric adenocarcinoma who have undergone gastrectomy.

METHODS

We reviewed demographic, clinical, and geriatric assessment variables, including recent falls, pain, performance status, American Society of Anesthesiologists score, assistive device use, comorbidity, polypharmacy, and weight change, for patients undergoing gastrectomy between 2005 and 2014. Outcome variables included morbidity, mortality, hospital length of stay, and readmission.

RESULTS

Of 279 patients, 133 (48%) underwent total gastrectomy. The 90-day major morbidity rate was 24% and the mortality rate was 1%. Length of hospital stay ≥ 14 days occurred in 38%, with readmission within 30 days in 13%. On multivariate analysis, gastroesophageal junction involvement, (odds ratio [OR] 2.5, 95% confidence interval [1.1-5.8]), additional organ resection, (OR 3.2, [1.6-6.3]), pain score >0 (OR 3.8, [1.6-8.7]), Eastern Cooperative Oncology Group performance status >0, (OR 2.3, [1.2-4.6]), and polypharmacy (OR 2.4, [1.1-5.2]) were associated with major morbidity. Hospital stay ≥ 14 days was associated with age ≥ 75 years (OR 3.9, [1.7-9.2]), total gastrectomy (OR 3.5, [2.0-6.3]), performance status >0 (OR 1.8, [1.0-3.2]), and preoperative chemotherapy (OR 0.3, [0.2-0.7]).

CONCLUSIONS

Future studies are needed to identify methods to improve performance status, as this may improve postoperative complications and resource utilization.