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.

Validation of Malayalam Translation of the European Organization for the Research and Treatment of Cancer Quality of Life Instrument OG25 for Esophagogastric Junction Cancers

Background:

Quality of life questionnaire (QLQ) OG25 is the questionnaire used for measuring quality of life (QOL) of patients with esophago-gastric junction (OG) cancers. QLQ-OG 25 is a disease-specific tool to capture the QOL parameters of patients with OG junction cancers. OG 25 was developed by the European Organization for the Research and Treatment of Cancer (EORTC) using inspiration from their questionnaires for carcinoma stomach (STO22) and carcinoma esophagus (OES18). It is usually used along with QLQ-C30, which is a general tool applicable for all cancers. This questionnaire is in the English language. In order to use this questionnaire in a non-English speaking population, the English questionnaire has to be initially translated to the local languages. Malayalam is the language spoken by 38.5 million people residing in the South Indian state, Kerala, India. We have translated and validated the QLQ-OG 25 to Malayalam language in an attempt of enabling it to be used for future studies at this geographic region.

Methods:

The translation was done by the standard protocol adopted by EORTC. QLQ-C30 and QLQ-OG25 questionnaires were then filled in by patients with OG junction cancers. These patients had cancers of various subsites of the OG junction and were at different stages of treatment, at the time of interview. The interview was done twice, at an interval ranging from 48 h to 1 week between the two interviews.

Results:

A total of 46 patients with OG junction tumors at varying stages of treatment completed the questionnaire. There were no missing data. The average time to finish the interview was 12.12 min. The Cronbach's alpha, which signifies the internal consistency of the questionnaire, was found to be >0.7 in all the domains studied, except in cognitive function. The intraclass correlation coefficients varied from 0.63 to 0.93.

Conclusion:

The Malayalam translation of the QOL tool QLQ-OG25 has been found to be an acceptable and valid tool in assessing the QOL parameters of patients with OG junction cancers.

Prognoses of advanced esophago-gastric junction cancer may be modified by thoracotomy and splenectomy

Globally, the incidence of esophago-gastric junction (EGJ) cancer is rapidly increasing. However, the proposed strategies for the treatment of these types of cancer are so diverse that there is no established consensus on the optimal treatment. The aim of the present study was to identify independent prognostic factors to delineate the optimal strategies for the treatment of EGJ cancer. The medical records of 150 patients with EGJ cancer who underwent curative surgery at the Kitasato University were retrospectively reviewed. The median follow-up period was 48 months. The patients with tumors that were classified as post-treatment primary tumor stage 3 [(y)pT3] or higher had a 5-year disease-specific survival (DSS) rate of 53%, whereas those with tumors that were classified as (y)pT0-2 had a 5-year DSS rate of 90%. Therefore, prognostic analysis was restricted to those tumors that were designated (y)pT3 or higher. A multivariate Cox's proportional hazards model identified the following independent prognostic factors that negatively influenced the DSS: i) Presence of tumors classified as post-treatment regional lymph node stage 1-3 [(y)pN1-3] [hazard ratio (HR), 3.62; 95% confidence interval (CI), 1.39-12.36]; ii) not undergoing treatment with splenectomy (HR, 2.40; 95% CI, 1.15-5.15); and iii) undergoing treatment with thoracotomy (HR, 2.07; 95% CI, 1.02-4.23). In patients with (y)pN0 tumors, the DSS rate was significantly improved for those who underwent splenectomy than for those who did not (P=0.024). In patients with (y)pN1-3 tumors, the DSS rate was significantly worse for those who underwent thoracotomy compared with those who did not (P=0.004). Splenectomy and thoracotomy may critically affect prognosis in locally advanced EGJ cancer that are classified as (y)pN0 and (y)pN1-3, respectively. Surgical treatments require optimization in order to improve prognoses in advanced EGJ cancer.

Prolonged measurement improves the assessment of the barrier function of the esophago-gastric junction by high-resolution manometry

BACKGROUND

Etiology of gastro-esophageal reflux disease (GERD) is multifactorial, but incompetence of the esophago-gastric junction (EGJ) appears to be of crucial importance. Established manometric parameters for assessment of EGJ barrier function are sub-optimal, potentially because they reflect only a very brief (up to 30 seconds), not necessarily representative period. This prospective, case-control study tested the performance of novel, high-resolution manometry (HRM) parameters of EGJ function in the assessment of GERD.

METHODS

Patients with reflux symptoms and healthy controls (HC) underwent standard HRM and 24-hour pH±impedance measurements. EGJ morphology, lower esophageal sphincter pressure integral (LES-PI), EGJ contractile integral (EGJ-CI) were compared with total-EGJ-CI, a novel parameter summarizing EGJ barrier function during the entire HRM protocol. Esophageal acid exposure ≥4.2%/24 h (A-Reflux-pos) or ≥73 reflux episodes in 24 hours (V-Reflux-pos) were considered pathological.

KEY RESULTS

Sixty five HC and 452 patients completed HRM, 380 (84%) patients underwent ambulatory reflux-monitoring. LES-PI, EGJ-CI and total-EGJ-CI correlated with EGJ morphology subtypes (all P<.00001). Only total-EGJ-CI was consistently lower in A-Reflux-pos and V-Reflux-pos subjects compared with HC and patients without GERD. Total-EGJ-CI was also the single best parameter for prediction of pathological reflux (optimal cut-off 47 mmHg cm, AUC 0.746, P<.0001). This cut-off value, approximately 1 SD below the mean normal value, showed modest sensitivity 54% and positive predictive value 46%, but good specificity 85% and negative predictive value 89% for GERD diagnosis.

CONCLUSION & INFERENCES

Total EGJ-CI, a new metric that summarizes EGJ contractility over time, allows an improved assessment of EGJ barrier function. Pathological reflux is unlikely if this metric is within the upper two-thirds of the normal range.

Benefits of xiphoidectomy in total gastrectomy: Technical note

OBJECTIVE

The esophago-gastric junction may be challenging during total gastrectomy due to gastric cancer. This situation may compromise the security of both the dissection and anastomosis. The purpose of this study was to investigate the usefulness of xiphoidectomy to overcome this issue.

MATERIAL AND METHODS

The files of patients who underwent total gastrectomy + D2 lymph node dissection due to proximal gastric cancer or cardia cancer between April 2002-December 2013 were retrospectively evaluated. We assessed the outcome in patients with xiphoidectomy in addition to the midline incision in terms of xiphoidectomy technique, xiphoidectomy time, and operative and postoperative complications.

RESULTS

Thirty cases were identified to undergo xiphoidectomy. Nineteen patients were male and 11 were female, with a mean age of 51 (21-80) years. The time required for xiphoidectomy was 7-15 minutes (mean 8.7 minutes). The mean additional time required for the closure of the incision in cases with xiphoidectomy was 2 minutes. There was minimal arterial bleeding from the diaphragmatic surface in one patient, which was controlled by electrocautery. Only two patients developed wound infection.

CONCLUSION

Performing xiphoidectomy is quite easy, after a certain learning phase. The operative time was 7-15 minutes longer due to excision of xiphoid and closure of the related defect. Minor hemorrhage was a problem during surgery. There were no early or late post-operative complications. We suggest that the procedure is beneficial in selected cases with requirement of a wider operative field or better exposure of the esophago-gastric junction during total gastrectomy for gastric cancer, and recommend removal of the xiphoid bone.

Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease

BACKGROUND

Measurement of esophago-gastric junction (EGJ) cross-sectional area (CSA) and distensibility by an Endolumenal Functional Lumen Imaging Probe (EndoFLIP®) may distinguish between gastro-esophageal reflux disease (GERD) patients and healthy volunteers (HV). We aimed to assess the agreement of EndoFLIP® measurements with clinical and physiologic diagnosis of GERD.

METHODS

Twenty-one HV and 18 patients with typical GERD symptoms were studied. After gastroscopy, EGJ CSA, and distensibility were measured by EndoFLIP®. Forty-eight hour esophageal pH monitoring was then performed by a wireless system. The ability of EndoFLIP® to discriminate GERD patient and HVs was assessed. Planned secondary analysis then assessed whether EGJ CSA and distensibility were increased in individuals with pathologic acid exposure.

KEY RESULTS

Healthy volunteers were younger and had lower body mass index (BMI; both p < 0.001). Pathologic acid exposure was present in 3/21 (14%) HVs and 9/18 (50%) patients (p = 0.126). At 30 mL EndoFLIP® bag volume, EGJ CSA was higher (p = 0.058) and EGJ distensibility was lower (p = 0.020) in HVs than patients. Secondary analysis showed that EGJ measurements were similar in participants with and without pathologic acid exposure (CSA 98 mm² vs 107 mm²; p = 0.789, distensibility; p = 0.704). An inverse association between BMI and CSA (R² = 0.2758, p = 0.001) and distensibility (R² = 0.2005, p = 0.005) was present.

CONCLUSIONS & INFERENCES

Endolumenal Functional Lumen Imaging Probe is not useful for GERD diagnosis because EGJ CSA and distensibility do not distinguish between HVs and GERD patients defined by clinical presentation or pH measurement. This unexpected result may be due to an important, confounding interaction of obesity.

Prevalence of Barrett's esophagus in Northern Greece: A Prospective Study (Barrett's esophagus)

BACKGROUND

Barrett's esophagus(BE) is a premalignant condition associated with chronic gastro-esophageal reflux disease (GERD). As only a small proportion of BE progresses to malignancy, it is important to study BE prevalence to prevent adenocarcinoma.

MATERIALS AND METHODS

Between January 2007 and December 2010, all consecutive individuals who underwent routine upper endoscopy were prospectively recruited. Patients referred for GERD were excluded from the study. Clinical and endoscopic data were collected.

RESULTS

A total of 1,990 patients (mean age 47.48±13.4 years; 52.8% males) were included. Of them, 496 (24.9%) reported GERD. Erosive esophagitis (EE) was found in 221 participants (11.1%, 193 patients with LA grade A and 28 patients with LA grade B). Overall 31 of 1494 participants not reporting reflux symptoms (2.07%) suffered from silent GERD. BE was diagnosed in 75 participants (3.77%), four (5.3%) with long-segment BE and 71 (94.7%) with short-segment BE. Low-grade dysplasia was noticed in 1 patient with long-segment BE. Hiatal hernia (HH) was found in 196 patients (9.8%), and mean HH length was 3.22 ± 0.2 cm. BE was correlated to EE, GERD and the presence of HH (p= 0.0167, <0.001 and 0.017, respectively) whereas it was not associated with age, alcohol consumption and smoking (p= 0.057, 0.099 and 0.06, respectively). BE was not correlated with Helicobacter pylori infection (p=0.542).

CONCLUSION

The prevalence of BE was 3.77% in a Greek population undergoing upper endoscopy not referred for GERD. Long-segment BE was very uncommon (0.2%) whereas 2.07% of patients not reporting symptoms suffered from silent GERD.