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

Comparison of proximal gastrectomy with tubular esophagogastric anastomosis and total gastrectomy with Roux-en-Y reconstruction in the treatment of adenocarcinoma of the esophagogastric junction of Siewert type II/III at stage II

BACKGROUND

Tubular anastomosis is commonly used in proximal gastrectomy; however, its use in stage II esophagogastric conjugate cancer is currently unclear. In this study, we investigated the short- and long-term clinical outcomes of Siewert II/III adenocarcinoma of the esophagogastric junction after modified proximal gastrectomy with tubular esophagogastric anastomosis compared with total gastrectomy with Roux-en-Y reconstruction.

METHODS

We collected the clinical data of patients who underwent proximal gastrectomy tubular esophagogastric anastomosis (PG-TEA) and total gastrectomy Roux-en-Y reconstruction (TG-RY) from October 2015 to October 2018. The clinical characteristics, postoperative quality of life, nutritional status, and long-term survival outcomes of the two groups were compared.

RESULTS

There were 43 patients in the PG-TEA group and 80 patients in the TG-RY group, and there was no significant difference between the baseline data of the groups. The operation time of the PG-TEA group was shorter, there was less intraoperative bleeding, and the feeding time was earlier, which was conducive to postoperative recovery. Reflux esophagitis was more evident in the PG-TEA group than in the TG-RY group, and there was no significant difference in the incidence of anastomotic ulcers or other complications. Three months after surgery, the nutritional status of the PG-TEA group was better than the TG-RY group. By the 6th postoperative month, there was no significant difference between the two groups. Regarding quality of life, the PG-TEA group was superior to the TG-RY group in terms of diarrhea and dumping syndrome. In addition, the PG-TEA group had higher satisfaction with daily life and higher-quality meals. There was no significant difference in overall survival between the two groups.

CONCLUSIONS

Proximal gastrectomy tubular gastroesophageal anastomosis is a surgical procedure for stage II Siewert type II and III AEG. It achieves similar clinical outcomes to those after total gastrectomy and can be further applied in the clinic.

Analysis of risk factors for intraoperative bleeding in patients with Siewert type II esophagogastric junction adenocarcinoma treated by two minimally invasive surgeries and its influence on prognosis: a retrospective study

Background

The present study aimed to analyze the independent risk factors for intraoperative bleeding in Siewert II adenocarcinoma of the esophagogastric junction (AEG) using two minimally invasive surgical approaches, namely, the laparoscopy-assisted abdominal trans-hiatal (LTH) method and transthoracic-laparoscopic esophagectomy (TLE).

Methods

The clinical data of 100 patients with SiewertII AEG admitted to our hospital from October 2017 to October 2020 were retrospectively analyzed. According to the type of surgery, the patients were divided into LTH approach group and TLE approach group. The differences between the clinical characteristics of the patients in different groups and the differences in the intraoperative bleeding and prognosis between different surgical procedures were analyzed and compared using the t-test and chi-squared test. Multiple linear regression was used to identify the independent risk factors affecting the amount of intraoperative bleeding in patients.

Results

The results of this study showed that patients in the LTH group had significantly less intraoperative bleeding and operative time and significantly better postoperative recovery than the TLE group. The results of multivariate linear regression showed that the combined trans-thoracic-abdominal approach (P=0.000), advanced age (P=0.014), larger BMI (P=0.000), and larger tumor diameter (P=0.001) were the independent risk factors influencing the increase in intraoperative bleeding.

Conclusion

In addition to the conventional factors that affect intraoperative bleeding, such as the patient's general condition, operation time, and tumor size, LTH surgery is another way to avoid intraoperative bleeding for Siewert type II AEG patients and can significantly improve postoperative recovery.

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.

Oesophagectomy or Total Gastrectomy for the Management of Siewert II Gastroesophageal Junction Cancer: a Systematic Review and Meta-analysis

BACKGROUND

There is no consensus on the ideal surgical management of patients with Siewert type II gastroesophageal junctional (GEJ) cancers. Due to its anatomical location, total gastrectomy and oesophagectomy are widely used methods of resection. The aim of this study was to determine the optimal surgical treatment of these patients.

METHOD

A systematic search of PubMed, Medline and Cochrane libraries was conducted for literature published between 2000 and 2022. Studies directly comparing oesophagectomy to gastrectomy for Siewert type II tumours were included. Outcome measures included rates of anastomotic leak, 30-day mortality, R0 resection and 5-year survival. Statistical analysis was performed using Review Manager 5.4.

RESULTS

Eleven studies involving 18,585 patients undergoing either oesophagectomy (n = 8618) or total gastrectomy (n = 9967) for Siewert type II GEJ cancer were included. There were no significant differences between the rates of anastomotic leak (OR 0.91, CI 0.59-1.40, p = 0.66) and R0 resection (OR 1.51, CI 0.93-2.42, p = 0.09). Patients undergoing total gastrectomy had a lower 30-day mortality (OR 0.66, CI 0.45-0.95, p = 0.03) and a greater 5-year overall survival (OR 1.49, CI 1.34-1.67, p < 0.001) compared to patients undergoing oesophagectomy. These differences were not statistically significant after excluding two large studies, which accounted for the majority of the total population in the analysis.

CONCLUSION

These results suggest that total gastrectomy results in lower 30-day mortality and improved overall survival in patients with Siewert type II GEJ cancer. However, interpretation of these results may be biased by the effect of two large studies.

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.