Clinical experience in radical lymphadenectomy for adenocarcinoma of the gastric cardia

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.

The optimal lymph node dissection in patients with adenocarcinoma of the esophagogastric junction

OBJECTIVE

The aim of this study was to refine the optimal lymph node dissection in Western patients with adenocarcinoma of the esophagogastric junction (AEG).

BACKGROUND

Lymphadenectomy is essential in addition to surgery for AEG. Asian studies continually present superior survival rates using a more extended lymphadenectomy compared with results reproduced in the West. Thus, the optimal extend of the lymphadenectomy remains unclear in Western patients.

METHODS

A retrospective cohort was conducted of patients with AEG from January 1st, 2003 to December 31st, 2011. All patients undergoing curatively intended surgery was included. Two types of resections were constructed; Res1 included patients where only the loco regional lymph nodes were removed (station 1-4, 7 and 9) and Res2 included the additional removal of the more distant stations 8 and/or 11.

RESULTS

We identified 510 patients with AEG. The highest frequency of lymph node metastases was seen in the loco regional stations 1-3, 7 and 9, ranging from 34% to 41.4%. There was no difference in overall survival between the two groups; the median survival rate for Res1 was 30.4 months compared to 24.1 months for Res2 (p = 0.157). Furthermore, the extend of lymph node dissection seemed to have no effect on survival (HR = 1.061, 95%CI 0.84-1.33).

CONCLUSION

No significant difference in survival between the extended and the less extended lymphadenectomy was found. The presence of metastases in distant lymph nodes indicates poor survival and may represent disseminated disease. We do not find evidence that supports an extended lymph node dissection in Western patients.

Evaluation of rational extent lymphadenectomy for local advanced gastric cancer

Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes (PAN) in JCOG9501, the clinical benefit of D2+ para-aortic nodal dissection (PAND) for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.11 nodes has been controversial, and however, the final results from the randomized trial of JCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as M1 stage in the current version of the Japanese classification. We propose that D2+No.14v and +No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.

Status and prognosis of lymph node metastasis in patients with cardia cancer - a systematic review

BACKGROUND

Adenocarcinoma of the gastroesophageal junction (GEJ) has a poor prognosis and survival rates significantly decreases if lymph node metastasis is present. An extensive lymphadenectomy may increase chances of cure, but may also lead to further postoperative morbidity and mortality. Therefore, the optimal treatment of cardia cancer remains controversial. A systematic review of English publications dealing with adenocarcinoma of the cardia was conducted to elucidate patterns of nodal spread and prognostic implications.

METHODS

A systematic literature search based on PRISMA guidelines identifying relevant studies describing lymph node metastasis and the associated prognosis. Lymph node stations were classified according to the Japanese Gastric Cancer Association guidelines.

RESULTS

The highest incidence of metastasis is seen in the nearest regional lymph nodes, station no. 1-3 and additionally in no. 7, 9 and 11. Correspondingly the best survival is seen when metastasis remain in the most locoregional nodes and survival equally tends to decrease as the metastasis become more distant. Furthermore, the presence of lymph node metastasis significantly correlates to the TNM-stage. Incidences of metastasis in mediastinal lymph nodes are associated with poor survival.

CONCLUSION

The best survival rates is seen when lymph node metastasis remains locoregional and survival rates decreases when distant lymph node metastasis is present. The dissection of locoregional lymph nodes offers significantly therapeutic benefit, but larger and prospective studies are needed to evaluate the effect of dissecting distant and mediastinal lymph nodes.

Lymphadenectomy around the left renal vein in Siewert type II adenocarcinoma of the oesophagogastric junction

BACKGROUND

The extent of lymphadenectomy in patients with Siewert type II adenocarcinoma of the oesophagogastric junction is controversial. The aim of this study was to investigate lymph node involvement around the left renal vein.

METHODS

Lymph node involvement and prognosis in patients with Siewert type II cancers treated by R0-1 surgical resection were investigated, with regard to lymphadenectomy around the left renal vein. Based on the incidence of involvement at each node, the node stations were divided into three tiers (first tier, more than 20 per cent involvement; second tier, 10-20 per cent involvement; third tier, less than 10 per cent involvement).

RESULTS

Of 150 patients with type II oesophagogastric adenocarcinoma, 94 had left renal vein lymphadenectomy. The first lymph node tier included nodes along the lesser curvature, right cardia, left cardia and left gastric artery, with involvement of 28·0-46·0 per cent and a 5-year survival rate of 42-53 per cent in patients with positive nodes. The nodes around the lower mediastinum, left renal vein, splenic artery and coeliac axis constituted the second tier, with involvement of 12·7-18 per cent and a 5-year survival rate of 11-35 per cent. With regard to the left renal vein, the incidence of involvement was 17 per cent and the 5-year rate survival rate was 19 per cent. Multivariable analysis showed that left renal vein lymphadenectomy was an independent prognostic factor in patients with pathological tumour category pathological T3-4 disease (hazard ratio 0·51, 95 per cent confidence interval 0·26 to 0·99; P = 0·048).

CONCLUSION

Left renal vein nodal involvement is similar to that seen along the splenic artery, in the lower mediastinum and coeliac axis, with similar impact on patient survival.

Risk factors for metastasis to para-aortic lymph nodes in gastric cancer: a single institution study in China

BACKGROUND

Para-aortic lymph node (PAN) dissection is performed in some gastric cancer patients with extensive lymph node involvement. However, there is no consensus on selection of patients that will benefit from this high risk dissection. This study was to identify risk factors for PAN metastasis in gastric cancer.

MATERIALS AND METHODS

A total of 174 patients with gastric cancer who underwent D2 lymphadenectomy plus para-aortic nodal dissection in Tianjin Medical University Cancer Institute and Hospital from January 2001 to December 2010 were enrolled in the study. The association between clinicopathologic factors and para-aortic nodal invasion was analyzed.

RESULTS

Forty-seven patients (27.0%) had PAN metastases. Pathologic N stage was a significant risk factor for PAN metastasis after adjusting for other factors. A significant difference was shown in the proportion of PAN metastases between the N0/N1 group and N2/N3 group (6.2% versus 45.2%, P < 0.001, OR = 12.620). Lymph node station 9 showed a much higher odds ratio with PAN metastases than other routinely retrieved stations.

CONCLUSION

N stage and perigastric nodal status were important and independent risk factors for PAN metastasis, which may be useful for identifying patients at high risk of PAN metastasis who could benefit from PAN dissection.

[Clinicopathological characteristics of Barrett's carcinoma, cardia carcinoma type II and distal gastric carcinoma: influence of observed parameters on the five-year postoperative survival of patients]

INTRODUCTION In the past two decades, the increased frequency of distal esophageal adenocarcinoma, esophagogastric junction and proximal gastric adenocarcinoma has been observed. The vast majority of these tumours are diagnosed in advanced stages, when the prognosis is poorer than in other gastric cancers.

OBJECTIVE

The aim of our study was to analyze the demographic and clinicopathological characteristics of patients operated on for Barrett's, cardia and distal gastric adenocarcinomas, as well as to study the influence of manifestations of each cancerogenetic indication on the studied clinicopathological parameters and to analyze the 5-year survival rate of patients surgically treated for cardia adenocarcinoma in relation to the patients operated on for distal gastric adenocarcinoma.

METHODS

We analyzed gender and age, tumour type, depth of tumour invasion, involvement of blood and lymph vessels in 66 patients surgically treated at the Centre for Oesophageal Surgery of the Institute for Digestive Diseases of the Belgrade Clinical Centre.

RESULTS

Except for significant differences in the depth of tumour invasion during surgery, there were no other statistically significant differences between the studied groups of patients. In the patients operated on for Barrett's and cardia cancers, the tumours invaded more deeply the wall layers, i.e. they were significantly more invasive than the distal gastric tumour. The lymph node involvement was present in 87.5% of patients with Barrett's cancer, in 80% with cardia cancer and in 87% with distal gastric cancer. The 3-year survival rate of patients operated on for cardia cancer was 47.4% and the 5-year survival rate was 31.6%, while the 3-year survival rate of patients operated on for distal gastric cancer was 46.2% and the 5-year survival rate was 34.6%. These differences were not statistically significant (Wilcoxon 0.036; p = 0.85). Singly, the patients' gender, cancer type and the degree of tumour differentiation had no influence on the length of patients' postsurgical survival rate.

CONCLUSION

At the time of diagnosis cardia cancer and cancers developed at the location of the Barrett's oesophagus, developed significant deeper per continuitatem than gastric cancer. There were no other differences in regard to the analyzed clinicopathological parameters among the tumours of these three locations, and there was no difference between the 3-year and 5-year survival rate between the patients operated on for gastric cancer and cardia cancer. Each studied clinicopathological parameter had no influence on the illness course.

An evidence-based medicine review of lymphadenectomy extent for gastric cancer

BACKGROUND

Several studies in the literature have investigated the possible role of the extent of lymphadenectomy in gastric cancer treatment failure. The current study attempted to determine the effectiveness and safety of lymphadenectomy with gastrectomy for the treatment of gastric cancer.

METHODS

Randomized controlled trials (RCTs) were identified by means of MEDLINE, EMBASE, Cochrane Controlled Trials Register databases, and Chinese Biomedical Database, as well as by selecting references from relevant articles.

RESULTS

Overall, 14 RCTs (3,432 patients) were included in the meta-analysis. Of the D1 and D2 surgery groups, the operative mortality and postoperative morbidity were higher in the D2 group than in the D1 group, but the 3- and 5-year survival rates were not statistically different. Also the operative time was shorter in D1 compared to D2. In the D2 versus the D3 surgical group, the operative mortality, percentage of postoperative complications, operative time, and hospital stay were not significantly different.

CONCLUSIONS

The results suggest that D2 and D3 surgery may not offer specific advantages for gastric cancer and instead may lead to disadvantages for patient outcomes.

Randomized clinical trial of D2 and extended paraaortic lymphadenectomy in patients with gastric cancer

BACKGROUND

The survival of patients with advanced gastric cancer after D2 dissection is still poor. Asian surgeons have proposed a more radical lymph node dissection, designated as D4 dissection, where paraaortic lymph nodes are removed in combination with D2 dissection. To evaluate the survival benefit of D4 dissection, a multi-institutional randomized trial of D2 vs D4 gastrectomy was conducted.

METHODS

Patients enrolled in the study had potentially curable gastric adenocarcinoma at an advanced stage. Patients were randomized to undergo either D2 or D4 gastrectomy.

RESULTS

Two hundred and ninety-three patients were registered and 269 patients were eligible; 135 patients were allocated to the D2 group and 134 to the D4 group. Five-year survival was 52.6% after D2 surgery and 55.0% after D4 gastrectomy. There was no significant difference in survival between the D2 and D4 groups (chi(2) = 0.064; P = 0.801). Hospital deaths occurred in 1 patients (0.7%) in the D2 group and 5 in the D4 group D4 gastrectomy is a more risky surgery than D2 dissection. Seven patients (5.2%) in the D2 and 15 (11.2%) in the D4 group died of causes other than gastric cancer recurrence. Sixty-three patients (46.7%) in the D2 group and 52 (38.8%) in the D4 group had disease recurrence.

CONCLUSION

Prophylactic D4 dissection is not recommended for patients with potentially curable advanced gastric cancer.

Lymph node involvement in advanced gastroesophageal junction adenocarcinoma

OBJECTIVE

The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement; nonetheless, few studies deal with the pattern of lymph node spread and specifically analyze the prognostic value of the site of metastasis. The present study was aimed at evaluating these key aspects in advanced gastroesophageal junction adenocarcinoma.

METHODS

Of 219 patients consecutively operated on for gastroesophageal junction adenocarcinoma at the Department of General Surgery and Surgical Oncology, University of Siena, and at the Department of General Surgery, University of Verona, 143 pT2-4 tumors not submitted to prior chemoradiation were analyzed according to the Japanese Gastric Cancer Association pN staging system.

RESULTS

The majority of patients were given diagnoses of nodal metastases (77.6%). The mean number (P = .076) and the percentage of patients with pN+ disease (P = .022) progressively increased from Siewert type I to type III tumors. Abdominal nodes were involved in all but 1 of the patients with pN+ disease; conversely, nodal metastases into the chest were 46.2% for type I, 29.5% for type II, and 9.3% for type III tumors. Survival analysis showed virtually no chance of recovery for patients with more than 6 metastatic nodes or lymph nodes located beyond the first tier.

CONCLUSIONS

In advanced gastroesophageal junction adenocarcinoma, the high frequency of nodal metastases and the related unfavorable long-term outcome achieved by means of surgical intervention alone are indicative of the need for aggressive multimodal treatment along with surgical intervention to improve long-term results.

Nodal Staging in Adenocarcinoma of the Gastro-Esophageal Junction. Proposal of a Specific Staging System

PURPOSE

This study was aimed at developing a proper nodal staging system for GEJ adenocarcinoma.

METHODS

The study analyzed 113 patients with GEJ adenocarcinoma consecutively resected at the Department of General Surgery and Surgical Oncology of the University of Siena and at the Department of General Surgery of the University of Verona. Both the number (TNM) and site (JGCA) of lymph node metastasis was evaluated in considering nodal staging.

RESULTS

The TNM and JGCA staging systems coincided only in 56.3% of cases. Nodal involvement resulted to be the most important prognostic factor considering both the staging systems (P < 0.001). An extremely poor prognosis and a prominent risk of death were observed for patients with more than six metastatic nodes (TNM pN2-3) as well as for patients with involvement of second and third tier nodes (JGCA pN2-3) (P < 0.001). The combined prognostic significance of the two classifications showed a similar risk of death for patients with less than seven metastatic nodes (TNM pN1) located beyond the first tier (JGCA pN2-3) and for patients with more than six involved nodes (TNM pN2-3) independently from the interested level (JGCA pN1-3). Accordingly, these classes were pooled together and four classes considered: pN0, TNM-JGCA pN1, TNM pN2-3 or JGCA pN2-3, M1a (P < 0.001).

CONCLUSIONS

The combination of the TNM and JGCA staging systems herein proposed is extremely practical from a clinical point of view and leads to the stratification of pN+ patients in two classes only with very different risk of death.

Pre-tracheal lymph node metastasis in squamous cell carcinoma of the thoracic esophagus

AIMS

To clarify the incidence of pre-tracheal lymph node metastasis in squamous cell carcinoma of the esophagus, and their impact on survival.

METHODS

A cohort of 101 patients with squamous cell carcinoma of the thoracic esophagus who underwent esophagectomy together with 2-field lymphadenectomy including the pre-tracheal region was analysed, retrospectively. The p-TNM staging included stage I in 9, stage IIa in 33, stage IIb in 4, stage III in 43, and stage IV in 12 cases.

RESULTS

Nodal metastases were identified in 56 patients (55.4%). Subcarinal lymph node and pre-tracheal lymph-node metastases were found in 24 patients (23.8%) and 15 patients (14.9%), respectively. The 5-year cumulative survival rates were 26.5 and 2.5% in nodal negative and nodal positive patients, respectively. Patients with pre-tracheal nodal metastasis all died within 2 years. Cox proportional hazards model in patients with nodal involvement revealed T-factor (p=0.0017), pre-tracheal nodal involvement (p=0.0055) and distant metastasis (p=0.0024) as independent prognostic factors.

CONCLUSIONS

Our findings suggest that pre-tracheal lymph node metastasis indicates a dismal prognosis. Its occurrence is not unusual, especially in tumour of upper or middle thoracic esophagus. The subcarinal node cannot be regarded as a sentinel node of the pre-tracheal nodal station. Complete lymphadenectomy excluding the pre-tracheal lymph nodes in treating esophageal cancers is only a myth.

Pattern of recurrence after surgery in adenocarcinoma of the gastro-oesophageal junction

AIMS

This study reports mode, timing and predictive factors of recurrence after curative surgery for cardia cancer.

METHODS

A prospective study in a series of 92 curatively (R0) resected patients from 1988 to 2002.

RESULTS

The 5-year recurrence rate was 71%. Lymph node involvement was the only predictor of recurrence. No patients with more than 6 metastatic nodes were free from relapse 2 years after surgery. Locoregional, peritoneal and haematogenous relapses showed a similar median recurrence time (12, 10 and 12 months, respectively), 80% occurred within 24 months.

CONCLUSIONS

Few patients can be cured by surgery, lymph nodal involvement is the only predictor of recurrence.

Surgical management of and long-term survival after adenocarcinoma of the cardia

BACKGROUND

The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions.

METHODS

From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively.

RESULTS

Fifty-six patients (44.4 per cent) had type I tumours, 44 (34.9 per cent) type II and 26 (20.6 per cent) type III. Primary resection was performed in 113 patients (89.7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51.6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48.4 per cent). In-hospital mortality and morbidity rates were 4.8 and 34.1 per cent respectively. The overall 3- and 5-year survival rates were 40.9 and 25.1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation.

CONCLUSION

Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches.

Results of surgical treatment of adenocarcinoma of the gastric cardia

BACKGROUND

Comparison among different studies regarding adenocarcinoma of the cardia has been difficult since the Siewert classification was introduced. This study analyzed the experience of a single institution in the treatment of gastric cardia cancer with the aim of assessing principal prognostic factors and long-term outcome.

METHODS

The results of 96 patients who underwent resection with curative intent for gastric cardia cancer at the First Division of General Surgery, University of Verona, from January 1988 to February 2000, were analyzed statistically with special reference to Siewert type.

RESULTS

Despite a high number of curative resections (85.4%), the 5-year survival rate was poor (24%) for all Siewert types (p = 0.8), and for early tumors (51%) also. Chance of cure was limited to pN0 and pN1 patients. Multivariate analysis showed that microscopic or macroscopic residual tumor and pN-positive categories had a significantly higher risk of death (risk ratio, 2.18 and 2.68, respectively) and the pN2 and pN3 category had the most negative prognostic factor (risk ratio, 7.6).

CONCLUSIONS

The long-term prognosis for gastric cardia cancer remains poor and is independent of Siewert type, with cure limited to pN0 and pN1 patients.

Surgical therapy for adenocarcinoma of the cardia: modalities of recurrence and extension of resection

In order to define the optimal extent of resection for cancer of the cardia, we considered 116 patients operated upon with five different surgical techniques. The procedures were: transabdominal total gastrectomy associated with distal esophagectomy in 38 patients; transabdominal total gastrectomy and left thoracotomic esophageal resection at the inferior pulmonary vein level in 26 patients; transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level in 27 patients; transabdominal total gastrectomy and transhiatal lower third esophagectomy in 18 patients; transhiatal total esophagectomy and upper third gastrectomy with cervical esophago-gastroplasty in seven patients. Grading, staging, neoplastic lymphangitis, satellite intramural metastases, infiltration of the resection margin, site of recurrence, and survival were analyzed. N+ was the single independent prognostic factor for survival. A poorly differentiated grading was related to T (P = 0.0009), N (P = 0.001), satellite growth (P = 0.05), and infiltration of the resection margin (P = 0.0001). Recurrence was local in 26% and distant in 74% of patients. The modalities of recurrence were not related to the aggressiveness parameters and the surgical technique. Infiltration of the esophageal resection margin was related to the type of operation (P = 0.005) and survival (P = 0.02), but it was not related to the site of recurrence. Transabdominal total gastrectomy and the right thoracotomic esophageal resection procedure achieved free margins and control of the lymph nodal metastatic spread. Transabdominal total gastrectomy and right thoracotomic esophageal resection at the azygos vein level provides a radical oncologic resection, particularly in poorly differentiated tumors. However, surgery alone cannot cure the majority of adenocarcinomas of the cardia.

Prediction of prognosis by the extent of lymph node involvement in squamous cell carcinoma of the thoracic esophagus

OBJECTIVES

Current criteria of the N-category in the TNM staging system for carcinoma of the esophagus needs further subgrouping due to its simplicity in mixing together patients with different prognosis.

METHOD

A retrospective cohort study of 186 patients (176 men and ten women; mean age, 59.9 years) with squamous cell carcinoma (SCC) of the thoracic esophagus who underwent esophagectomy followed by two-field lymphadenectomy and cervical lymph node sampling between 1992 and 1999 was conducted. A proposed N-category which involved dividing the nodal status into N0 (no nodal involvement), N1 (< or =4 nodes or < or =20% nodal involvement), and N2 (>4 nodes, or >20%, or non-regional nodal involvement) subgroups was used for survival analysis.

RESULTS

The overall 5-year cumulative survival rate was 27%. Lymph node metastases were identified in 101 (54.3%) patients. Cumulative survival rates were 46% at 4 years in the N0 group and 21% at 4 years in the N1 group, whereas no patients in N2 group survived longer than 3 years (P<0.01). A multivariable analysis revealed that independent prognostic factors included the depth of tumor invasion (P<0.01), nodal involvement (P<0.01), and organ metastasis (P<0.01).

CONCLUSION

In addition to the location of nodes, the extent of nodal involvement in SCC of the thoracic esophagus also plays an important role in prognosis prediction.

Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients

OBJECTIVE

To assess the outcome of surgical therapy based on a topographic/anatomical classification of adenocarcinoma of the esophagogastric junction.

SUMMARY BACKGROUND DATA

Because of its borderline location between the stomach and esophagus, the choice of surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial.

METHODS

In a large single-center series of 1,002 consecutive patients with adenocarcinoma of the esophagogastric junction, the choice of surgical approach was based on the location of the tumor center or tumor mass. Treatment of choice was esophagectomy for type I tumors (adenocarcinoma of the distal esophagus) and extended gastrectomy for type II tumors (true carcinoma of the cardia) and type III tumors (subcardial gastric cancer infiltrating the distal esophagus). Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor types, focusing on the pattern of lymphatic spread, the outcome of surgery, and prognostic factors in patients with type II tumors.

RESULTS

There were marked differences in sex distribution, associated intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, and stage distribution between the three tumor types. The postoperative death rate was higher after esophagectomy than extended total gastrectomy. On multivariate analysis, a complete tumor resection (R0 resection) and the lymph node status (pN0) were the dominating independent prognostic factors for the entire patient population and in the three tumor types, irrespective of the surgical approach. In patients with type II tumors, the pattern of lymphatic spread was primarily directed toward the paracardial, lesser curvature, and left gastric artery nodes; esophagectomy offered no survival benefit over extended gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophagogastric junction into type I, II, and III tumors shows marked differences between the tumor types and provides a useful tool for selecting the surgical approach. For patients with type II tumors, esophagectomy offers no advantage over extended gastrectomy if a complete tumor resection can be achieved.

Proximal versus distal gastric carcinoma--what are the differences?

BACKGROUND

The incidence of proximal gastric third carcinoma (PGC) has been rising in recent years. Classification and surgical therapy remain controversial.

METHODS

Between May 1986 and October 1997, 532 patients were operated for primary gastric carcinoma. All patient data were analyzed retrospectively comparing findings in patients with PGC and those with distal gastric carcinoma (DGC).

RESULTS

Two hundred fifty patients had a PGC, and 282 patients had a DGC. The rate of RO resections was 79.3% for PGC and 81.6% for DGC. In 93.9% of the patients with PGC total gastrectomy was performed; for DGC total gastrectomy was done in 74.5% of patients. Postoperative morbidity and mortality were 29.2% for PGC and 23.8% for DGC, and 3.2% for PGC and 3.5% for DGC, respectively. Patients with advanced tumor stages (stage III and IV) were more common in the PGC group (73.3% vs. 53.6% in DGC). After RO resection, the 5-year survival rate was 33.2% for PGC and 59.7% for DGC.

CONCLUSIONS

There was no significant difference between the rates of RO resections for PGC and DGC. Total gastrectomy can be performed with low postoperative morbidity and mortality. PGC and DGC represent the same tumor entity, and prognosis is similar, but due to more advanced tumor stages, the long-term survival is worse for patients with PGC than for those with DGC. Left retroperitoneal lymphadenectomy may be indicated for PGC.

Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma

AIMS

The management of anastomotic leakage of the oesophago-jejunostomy after total gastrectomy for gastric carcinoma was evaluated in a retrospective study.

PATIENTS AND METHODS

Over a 30-year period, a total of 1114 oesophago-jejunostomies were performed during total gastrectomy for gastric cancer. In 83 cases (7.5%) a leak of the oesophago-jejunostomy was diagnosed.

RESULTS

Frequency of anastomotic leakage was independent of the type of reconstruction and of surgical radicality. Therapeutic management was conservative in 58 cases (69.9%), with placement of a naso-jejunal tube along the anastomoses and with percutaneous drainage of intraabdominal abscesses. In 25 patients re-operation with resuturing of the anastomoses or surgical drainage of an abscess was performed. Mortality was 11/58 (19%) after conservative treatment of the anastomotic leakage and 16/25 (64%) after re-operation.

CONCLUSION

Conservative management with a naso-intestinal tube and percutaneous drainage of intraabdominal abscesses is realistic for anastomotic leaks. Re-operation results in a high morbidity and should only be considered when conservative management is not successful.