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.     

Individualized surgical strategies for cancer of the esophagogastric junction

Due to their borderline location between the stomach and esophagus the optimal surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial. Irrespective of the surgical approach a complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of surgical treatment of such tumors. Based on the experience with surgical resection of more than 1000 patients with adenocarcinoma of the esophagogastric junction we recommend an individualized surgical strategy guided by tumor stage and topographic location of the tumor center or tumor mass. This requires detailed preoperative staging and classification of tumors arising in the vicinity of the esophagogastric junction into adenocarcinoma of the distal esophagus (AEG Type I Tumors), true carcinoma of the gastric cardia (AEG Type II Tumors) and subcardial gastric carcinoma infiltrating the esophagogastric junction (AEG Type III Tumors). In patients with Type I Tumors transthoracic esophagectomy offers no survival benefit over radical transmediastinal esophagectomy, but is associated with higher morbidity. In patients with Type II or Type III tumors an extended total gastrectomy results in equal or superior survival and less postoperative mortality than a more extended esophagogastrectomy. In patients with early tumors, staged as uT1 on preoperative endosonography, a limited resection of the proximal stomach, cardia and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment allows a complete tumor removal with adequate lymphadenectomy and offers excellent functional results. Multimodal treatment protocols with neoadjuvant chemotherapy or combined radiochemotherapy followed by surgical resection appear to markedly improve the prognosis in patients with locally advanced tumors who respond to preoperative treatment. With this tailored approach extensive preoperative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.     

Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome

OBJECTIVE: To determine whether the length of esophageal resection or the operative approach influences outcome for patients with adenocarcinoma of the gastroesophageal junction (GEJ). SUMMARY BACKGROUND DATA: While R0 resection remains the mainstay of curative treatment of patients with GEJ cancer, the optimal length of esophageal resection remains controversial. METHODS: Patients with Siewert I, II, or III adenocarcinoma who underwent complete gross resection without neoadjuvant therapy were identified from a prospectively maintained database. Proximal margin lengths were recorded ex vivo as the distance from the gross tumor edge to the esophageal transection line. Operative approaches were grouped into gastrectomy (limited esophagectomy) or esophagectomy (extended esophagectomy). RESULTS: From 1985 through 2003, 505 patients underwent R0/R1 gastrectomy (n = 153) or esophagectomy (n = 352) without neoadjuvant treatment. There were no differences in R1 resection rate, number of nodes examined or operative mortality between gastrectomy and esophagectomy. Univariate analysis found >3.8 cm to be the ex vivo proximal margin length (approximately 5 cm in situ) most predictive of improved survival. Multivariable analysis in patients who underwent R0 resection with >or=15 lymph nodes examined (n = 275) found the number of positive lymph nodes, T stage, tumor grade, and ex vivo proximal margin length >3.8 cm to be independent prognostic factors. Subset analysis found that the benefit associated with >3.8 cm margin was limited to patients with T2 or greater tumors and 相似文献   

Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?

BACKGROUND: The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer. STUDY DESIGN: Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months. RESULTS: Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers. CONCLUSIONS: Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.     

Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors

BACKGROUND: Resection for adenocarcinoma of the gastroesophageal junction (AGEJ) is associated with severe mortality and morbidity. This retrospective study aimed to evaluate mortality and morbidity after resection for AGEJ and to determine their predictive factors. STUDY DESIGN: Data from 1,192 patients (mean age 65 +/- 11 years) who underwent resection for AGEJ by members of French Association of Surgery from 1985 to 2000 were collected. A stepwise logistic regression model was built to identify by multivariate analysis the variables independently associated with mortality, morbidity, anastomotic leakage, and major pulmonary complications. RESULTS: Distribution of Siewert's type was: I = 480 (40%), II = 500 (42%), and III = 212 (18%). Most type I and II tumors were treated by esophagectomy and proximal gastrectomy (93% and 58%, respectively), using an approach including a thoracotomy (82% and 64%, respectively); type III tumors were treated mainly by total gastrectomy and distal esophagectomy (83%), through an exclusive transabdominal approach (69%). Seventy-six (6%) patients died postoperatively. Only American Society of Anesthesiologists (ASA) scores III and IV (p < 0.001) and period of study (p = 0.025) were predictive of mortality. Predictive factors of overall morbidity (overall rate = 35%) were high ASA score (p < 0.001), age more than 60 years (p = 0.020), male gender (p = 0.039), and cervical anastomosis (p = 0.001). Factors predictive of anastomotic leakage (overall rate = 9%) were high ASA score (p = 0.006) and manual anastomosis (p = 0.010). Factors predictive of major pulmonary complications (overall rate = 23%) were high ASA score (p = 0.015), age more than 60 years (p < 0.001), anastomotic leakage (p < 0.001), and abdominal complications (p = 0.003). CONCLUSIONS: ASA score is a reliable predictive factor of operative mortality and morbidity after resection of AGEJ.     

Results of surgical therapy of adenocarcinomas of the esophagogastric junction according to a standardized surgical resection technique

AIM: The aim of this retrospective analysis was to exclusively present the surgical results of patients with type-I-III adenocarcinomas of the esophagogastric junction thereby providing a basis for comparison with other approaches. METHODS: 56 patients with Barrett's carcinomas and 74 patients with cardial and subcardial tumors were operated on and evaluated. The surgical procedure for type-II/III carcinomas was identical: total gastrectomy, omentectomy and splenectomy with lymph node dissection after a combined left thoraco-abdominal incision. Both tumor entities were summarized into 1 group and compared with the results of surgery for Barrett's carcinomas: subtotal esophagectomy and proximal stomach resection with lymph node dissection after right thoracotomy and an additional abdominal incision. RESULTS: In 93% of all patients an R0 resection was possible. In patients with Barrett's carcinomas pulmonal complications (41%) were the predominant postoperative problems. The 30-day lethality (5.3%) was higher in the group of patients with type-I carcinomas compared to those with type-II/III carcinomas (1.4%). Tumor infiltration and nodal involvement determined the prognosis after R0 resection. The presence of Barrett's mucosa in type-I adenocarcinomas and the histological assessment according to Lauren's classification into type-II/III carcinomas also influenced the long-term prognosis. CONCLUSION: After R0 resection it is not the tumor location but tumor infiltration, lymph node status and a differentiated histological assessment that determine the prognosis of patients with adenocarcinomas of the esophagogastric junction.     

Laparoscopic resection of gastric stromal tumor: a tailored approach

Many different laparoscopic approaches to resection of gastric stromal tumor have been described in the literature. We reviewed our experience of laparoscopic approaches to surgical resection of gastric stromal tumors seven in six consecutive patients. The tumor locations were the gastric cardia (n = 2), gastroesophageal junction (n = 1), gastric fundus (n = 2), and gastric antrum (n = 2). Laparoscopic localization of endoluminal tumors included intraoperative endoscopy, laparoscopic ultrasound, and laparoscopic palpation. There were five males with a mean age of 57 years. Laparoscopic approaches to resection were laparoscopic wedge resection (n = 4) for tumors in the gastric fundus and antrum, laparoscopic enucleation (n = 2) for tumors in the gastric cardia, and transgastric endoluminal resection (n = 1) for a tumor located at the gastroesophageal junction. There was no conversion to laparotomy. The mean operative time was 143 +/- 54 minutes and mean blood loss was 57 +/- 27 mL. None of the patients required intensive care stay. The mean length of hospital stay was 3 days. There were no major or minor complications and no mortality. Surgical pathology demonstrated gastric stromal tumor with less than 2/50 mitosis per high power field in all seven specimens. Tumor size ranged from 2.8 cm to 7.1 cm in greatest diameter. There has been no tumor recurrence with a mean follow-up of 9 months. Laparoscopic resection of benign gastric stromal tumor is safe and feasible. The laparoscopic approaches to surgical resection should be tailored based on the location and characteristics of the tumor.     

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

BACKGROUND AND AIMS: Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy. MATERIALS AND METHODS: One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed. RESULTS: Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis. CONCLUSION: Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.     

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial

OBJECTIVE: To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. BACKGROUND: A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. METHODS: A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. RESULTS: After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). CONCLUSION: There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.     

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食管胃结合部腺癌(AEG)的发病率呈持续上升趋势,尤其是在西方国家,增长速度远远高于东方国家。对于SiewertI型AEG,其生物学特性和外科治疗方案更接近于食管癌;对于SiewertⅡ、Ⅲ型AEG,外科治疗方案更接近于胃癌。目前有两个大型的Ⅲ期临床试验比较了不同术式的效果:SiewertI型AEG建议采用经胸切除的手术;而SiewertⅡ、Ⅲ型肿瘤建议采用开腹经食管裂孔的术式。同时,围手术期化疗、化放疗的作用也在临床试验中得到了进一步证实。     

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近年来,食管胃结合部腺癌(AEG)发病率呈上升趋势,手术为该病的主要治疗手段,但目前国人对该病概念较模糊,导致手术选择(包括手术入路、切除范围、淋巴结清扫范围等方面)多样,甚至存在争议。对肿瘤进行充分的分型、分期评估,遵循个体化治疗原则,是为病人选择科学合理的术式的前提和基础。对于SiewertI型AEG病人可行经胸经裂孔食管下段切除术、经颈、胸、腹三切口手术等;SiewertⅡ型AEG病人术式选择和手术入路存在较多的争议,经腹行全胃切除+腹部及纵隔淋巴结清扫被认为是进展期SiewertⅡ型AEG的首选术式,只有全胃切除才能保证进展期AEG足够无瘤切缘和淋巴结清扫范围,早期SiewertⅡ型AEG病人可行近端胃切除及相应淋巴结清扫;Ⅲ型AEG则按近端胃癌手术原则处理。进展期AEG是否联合脾切除尚存争议。目前不建议行常规脾切除术,只有在脾门受侵或有明确的淋巴结转移时,才考虑行脾切除。     

Adenocarcinoma of the esophago-gastric junction.

BACKGROUND: The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification. METHODS: In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations. RESULTS: The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients. CONCLUSION: The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.     

Ergebnisse der primär chirurgischen Therapie beim Adenokarzinom des ösophagogastralen Übergangs

INTRODUCTION: The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide, and classification systems and resection procedures are being controversially discussed. METHODS AND PATIENTS: We report on 225 AEG patients undergoing primary resection in our unit (1986-2000) with a special focus on perioperative morbidity, mortality, and long-term prognosis under consideration of the AEG type (Siewert classification) and operative procedure performed (subtotal esophagectomy with proximal gastric resection in AEG I, total gastrectomy with distal esophageal resection in AEG II and AEG III). RESULTS: Types I, II, and III carcinomas were found in 32%, 42%, and 26% of the patients, respectively, with R(0) resections in 65%, 69%, and 51% ( P=0.039). The overall 5-year survival rates were 29%, 31%, and 14% ( P=0.068), respectively; in R(0)-resected patients, they were 40%, 41%, and 27% ( P=0.771). In univariate analysis, the TNM classification ( P<0.001), R classification ( P<0.001), and tumor stage ( P<0.001) were relevant prognostic factors. In multivariate analysis, only the R classification ( P=0.003), LN ratio ( P=0.012), and N stage ( P=0.027) were independent prognostic factors. In 35 of 177 patients resected with curative intent, R(0) resections could not be achieved, mainly because of residual tumor in the circumferential plane (22/35=63%). Only in 37% of cases (13/35) was the R(1) situation due to exclusive positive oral or aboral resection margins. Therefore, in only 7% of all patients resected with curative intent (13/177) did the question arise of whether the R(1) resection could have been avoided by a different surgical approach. Surgical, pulmonary, and cardiac complications were found in 33%, 26%, and 10%, respectively. The mortality within 30 days was 4%. CONCLUSIONS: Failure of R(0) resection in patients treated with curative intent is mostly caused by residual tumor in the circumferential plane. Therefore, different surgical approaches with varying oral and aboral resection margins are of minor importance for reducing the frequency of R(1) resections. Downstaging of tumors by neoadjuvant treatment may increase the R(0) resection rate.     

Surgical treatment of adenocarcinoma of the cardia.

BACKGROUND. Adenocarcinoma of the gastric cardia presents different features from other gastric carcinomas. This study was performed to analyze the results of a 40-year experience with these lesions. METHODS. Of the 365 patients reviewed, 211 (57.8%) underwent resection. One hundred fifty patients underwent total gastrectomy with lower esophageal resection (TGER) and 46 underwent proximal gastrectomy with distal esophageal resection (PGER). More recently, 15 patients were submitted to total gastrectomy with subtotal esophagectomy (TGSE) without thoracotomy. RESULTS. The tumors were far advanced in most patients: extraparietal invasion in 77.7% of patients, lymph node involvement in 55%, and distant metastases in 11%. The postoperative mortality rate was 25.1% in patients who underwent resection: 26.7% after TGER, 17.4% after PGER, and 33.3% after TGSE (difference not significant). Cardiovascular and respiratory complications were common causes of death after both TGER and PGER. After TGSE, deaths were related exclusively to local complications, mainly as a result of cervical anastomotic leaks. The actuarial 5-year survival rate for all patients surviving resection was 16.7%. No improvement in the results of surgical therapy was observed during the past 20 years. The actuarial 5-year survival rate was significantly affected by pathologic staging: 61.0% stage I, 23.3% stage II, 9.8% stage III, and 0% stage IV (p less than 0.001). No significant differences in actuarial 5-year survival rates were observed between TGER (17.8%) and PGER (14.9%). Sex, duration of symptoms, and histologic type did not reveal prognostic significance. CONCLUSIONS. In early tumors a total gastrectomy with resection of 10 cm of esophagus above the tumor is advocated.     

The choice of surgical therapy in adenocarcinoma of the cardia

AIM: From 1996 the adenocarcinoma of the esophago-gastric junction (AEG) is divided into 3 types according to Siewert's classification. For AEG type I and III the surgical treatment is codified, while for type II is still controversial. The aim of our study is to understand what is the better surgical treatment for AEG type II. METHODS: From 1990 to 2002 we have performed 111 resections for adenocarcinoma of the cardia: 25 for AEG type I (all esophago-gastric resection), 39 for type II (22 esophago-gastric resection, 17 extended total gastrectomy with esophageal resection) and 47 for type III (8 esophago-gastric resection, 39 extended total gastrectomy with esophageal resection). RESULTS: The morbidity and mortality rates are 17 and 5.4%, without significant difference between the different surgical treatment (p>0.01). The 5 year survival rate is 35%. Significant prognostic factors are the staging TNM (p=0.002) and principally the presence of metastatic lymph nodes (p=0.001). For AEG type II any significant difference in survival is associated with surgical strategy, also in early stage (p>0.01). CONCLUSIONS: According to the results of our study and those of the other authors, who have showed that a 10 cm distance of the neoplasm by the gastric side and the esophageal one could assure oncologic radicality and also that metastatic lymph nodes below pylorus and near greater curvature are uncommon, we can consider esophago-gastric resection for AEG II a speedy, safe and oncologically correct surgical treatment.     

Lower mediastinal lymph node metastasis is an independent survival factor of Siewert type II and III adenocarcinomas in the gastroesophageal junction

We examined clinicopathological features and surgical outcomes in patients with adenocarcinoma in the gastroesophageal junction (GEJ), while also analyzing the survival factors that have a prognostic impact. Between 1991 and 2009, 61 patients with tumors in the GEJ (Siewert type II and III) underwent primary surgical resection. Thirty of 61 patients had type II tumors (49.2%) and 31 had type III tumors (50.8%). The tumor size was larger in type III tumors than type II tumors (P = 0.0026). The overall 5-year survival rates in patients with type II tumors and type III tumors were 44.2 per cent and 41.4 per cent, respectively, with no significant differences (P = 0.1888). The independent survival factors were lower mediastinal lymph node metastasis (P = 0.0323) and a noncurative resection (P = 0.0442). The independent survival factors for patients who underwent curative resections were the tumor size (P = 0.0422), M category (P = 0.0489), and lower mediastinal lymph node metastasis (P = 0.0482). This study showed lower mediastinal lymph node metastasis to be an independent survival factor, and also suggested that lower mediastinal lymph node metastasis was associated with distant metastasis in patients with adenocarcinoma in the GEJ (Siewert type II and III). Therefore, the preoperative early detection of such metastasis is important to improve patient survival.     

Laparoscopic enucleation or wedge resection of benign gastric pathology: analysis of 44 consecutive cases

Laparoscopic resection of gastric submucosal tumors has been described, but the role of laparoscopy for tumors within the esophagus or near the gastroesophageal junction is not clearly defined. The aim of this study was to examine the outcomes of laparoscopic or thoracoscopic enucleation or wedge resection of benign gastric tumors. The charts of 44 patients who underwent minimally invasive resection of benign esophagogastric tumors were reviewed. Surgical approaches included thoracoscopic enucleation (n = 2), laparoscopic enucleation (n = 6), transgastric enucleation (n = 2), and laparoscopic gastric wedge resection (n = 34). There were 23 males with a mean age of 57 years. There was one conversion (2.5%) to laparotomy. Mean operative time was 97 ± 52 minutes. The mean length of hospital stay was 2.6 ± 2.0 days. One patient developed gastric outlet obstruction requiring Roux-en-Y reconstruction. There were no leaks and the 90-day mortality was zero. Pathology demonstrated gastrointestinal stromal tumor (n = 31), leiomyoma (n = 6), and other benign pathology (n = 7). There has been one tumor recurrence at a mean follow-up of 4.3 years. The laparoscopic approaches to local resection of gastric tumors are safe and feasible. The type of minimally invasive surgical approaches should be tailored based on the location and size of the lesion.     

食管胃结合部腺癌的外科治疗

食管胃结合部癌的发病率呈持续上升的趋势,尤其是在西方国家。外科手术切除仍然是治疗食管胃结合部癌的基石。由于肿瘤位于食管和胃的结合部,所以对其定义、分型、分期和手术方式都还存在一些争议。Siewert分型是目前认可程度最高的分型方法。对于进展期SiewertⅠ型食管胃结合部癌,其生物学特性和外科治疗方案更接近于食管癌;对于进展期SiewertⅡ、Ⅲ型食管胃结合部癌,外科治疗方案更接近于胃癌。而对于早期食管胃结合部癌,可以采用内镜切除或者缩小手术。     

Surgical treatment of the adenocarcinoma of the cardia

Adenocarcinomas of the esophagogastric junction?should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III) in a pathogenic and therapeutic point of view. During a 15-year period (1995 - 2009), 117 surgical laparotomies for adenocarcinoma of the cardia were performed in elective surgery in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana. The classification was performed by summarizing the information obtained from oral contrast radiography, endoscopy, and intra-operative findings. There were 54 (46%) patients of Type I, 40 (34%) of Type II and 23 (20%) of Type III . Surgical procedures included "subtotal esophagectomy and proximal gastrectomy", "distal esophagectomy and proximal gastrectomy", "total gastrectomy and distal esophagectomy".?All anastomoses performed in the above mentioned procedures were hand sewn. Thirty-seven patients (32%) resulted inoperable at the time of laparotomy and 80 (68%) patients were treated with curative intent, those resulting in an operability index of 68%. The overall morbidity and mortality rates of 29% and 4,3% respectively.     

Lymph node metastasis with adenocarcinoma of the gastric cardia: clinicopathological analysis and indication for D1 dissection.

PURPOSE: To establish the indications for proximal resection with dissection of perigastric lymph nodes in order to treat adenocarcinoma of the gastric cardia. METHODS: We analyzed the clinicopathological features of 110 resected adenocarcinomas of the gastric cardia with respect to the appropriate operative method and extent of lymphadenectomy for treatment. RESULTS: Of the 110 patients, 93 underwent curative resection. The D2 group (total gastrectomy with dissection of extended regional lymph nodes) revealed higher morbidity and mortality rates compared to the D1 group (proximal resection with dissection of perigastric lymph nodes). The risk of lymph node metastasis was determined by depth of invasion, size of tumors, and gross findings of tumors. CONCLUSION: The appropriate operative method for adenocarcinoma of the gastric cardia requires: (i) tumor size less than 4 cm; and (ii) gross findings indicating a superficial type of lesion, which are recommended for proximal resection with dissection of perigastric lymph nodes.