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.     

Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia

BACKGROUND: A thoracoabdominal approach has traditionally been described for the resection of tumours of the gastric cardia. The aim of this study was to evaluate a transhiatal approach for resection of cancers of the gastric cardia. METHODS: Twenty consecutive patients undergoing transhiatal gastro-oesophagectomy for cancer of the gastric cardia were studied. Data were collected prospectively with regard to operating time, operative blood loss, intensive care unit (ICU) stay, analgesia use, duration of hospital stay, and pathological details of resection margin clearance and lymph node yield. Results were compared with those of the 20 preceding patients for whom the same prospective information had been recorded following resection via the standard thoracoabdominal approach. RESULTS: The transhiatal approach required a shorter operating time (median 190 (range 105-255) versus 280 (225-330) min; P = 0.004). It resulted in less blood loss (median 405 (180-2000) versus 1000 (420-3200) ml; P = 0.03) and fewer days in the ICU (median 0 (0-31) versus 2 (1-8) days; P = 0.005) despite being performed in an older patient population (median 71 (43-78) versus 63 (59-70) years; P = 0.016). There was no difference in either the lymph node harvest or length or involvement of upper resection margins. CONCLUSION: The transhiatal approach to the resection of tumours at the gastric cardia is a valid and safe alternative to the standard thoracoabdominal technique. This technique avoids thoracotomy and its associated morbidity and is accompanied by reduced blood loss, decreased operating time and a shorter ICU stay.     

Thoracoabdominal total gastrectomy in the management of adenocarcinoma of the cardia. Is it worth it?

A series of 47 consecutive patients with adenocarcinoma of the gastric cardia presenting between 1982 and 1987 have been reviewed. Of these, 38 patients were eligible for surgery (operability rate of 80.85%) but only 25 patients underwent potentially curative resection (resection rate of 65.7%). The disease was extensive at the time of operation, with only two patients (8%) having node negative tumours. The mean hospital stay for patients undergoing resection was 21 days. There were 15 major complications in 10 patients undergoing resection, but a zero 30-day mortality rate. The prognosis of those patients undergoing radical resection remains dismal. No patient survived longer than 30 months, 80% were dead within 1 year. Tumour recurrence and metastases were documented in 13 patients (52%). In the unresectable group there were two deaths from intubation (9%). The mean hospital stay for this group of patients was 12 days. The mean duration of survival in the group was 5.4 months, 70% of patients dying within 6 months and 95% dead within 1 year. The value of radical surgery in patients with adenocarcinoma of the gastric cardia is questioned.     

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.     

Total gastrectomy versus partial gastrectomy of adenocarcinoma of the antrum. A French prospective controlled study

In a prospective multicentric trial we compared the post-operative mortality and the 5-year survival of elective total gastrectomy (TG) versus subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study: thirty two were excluded after pathological examination (linitis plastica, superficial cancer, lymphoma). One hundred and sixty nine patients remained for analysis with 93 TG and 76 SG. Elective TG did not increase post-operative mortality (1.3%) in comparison with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both operations TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.     

Total gastrectomy is not always necessary for advanced gastric cancer of the cardia

BACKGROUND: It is unclear whether total gastrectomy (TG) is always necessary for gastric cancer of the cardia. We therefore investigated whether cardiac cancers treated by TG would have been cured by proximal gastrectomy (PG). METHODS: Photocopies of the resected stomachs of 55 patients who had received TG for cardiac cancer were reviewed. A simulated resection line for PG was drawn connecting a point 5 cm from the pyloric ring on the lesser curvature with a point 15 cm from the pyloric ring on the greater curvature. The distal surgical margin between the tumor edge and the simulated resection line was measured, and lymph nodes (LN) dissected surgically were examined for tumor involvement. RESULTS: Tumor location fell into three categories, upper-middle (UM, n = 28), upper (U, n = 18), and upper-esophagus (UE, n = 9). The means of the simulated surgical margins were 1.0 cm for UM, 4.7 cm for U, and 5.7 cm for UE tumors. UE tumors had no metastasis to No. 4d, 5, or 6 LN, and only one U tumor showed metastasis to No. 4d and 5 LN. In contrast, UM tumors had a higher incidence of these nodes involved. CONCLUSION: Advanced gastric cancer located in the U or UE regions is mostly curable by PG.     

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.     

Total gastrectomy in the treatment of advanced gastric cancer

To assess the role of total gastrectomy in the treatment of advanced gastric cancer, we reviewed the records of 27 patients who underwent the procedure from 1979 to 1988. Operative mortality was 4 percent (1 of 27), and postoperative morbidity occurred in 48 percent of the patients. Twenty-five of 26 patients were tolerating solid food at the time of discharge; 21 were able to maintain oral alimentation until just prior to their death. Median survival following the operation was 15 months (range: 2 to 110 months), with a 62 percent absolute 1-year survival rate and a 38 percent 2-year survival rate. On the basis of these results, we conclude that in patients with advanced gastric carcinoma, total gastrectomy with Roux-Y esophagojejunostomy can be performed with an acceptable morbidity and mortality, provides significant palliation by restoring the patient's ability to eat, and should be performed when technically feasible, even in the presence of gross residual disease.     

Adenocarcinoma of the cardia: treatment by thoracoabdominal R3 radical gastrectomy

The complications and mortality rate of R3 radical gastrectomy using a left thoracoabdominal approach were studied in 38 patients with adenocarcinoma of the gastric cardia. There were two hospital deaths and two anastomotic leaks. There was a high rate of complications following surgery (subphrenic abscess, eight; severe chest infection, five; aspiration pneumonia, two; wound infection, two; and reactivation of tuberculosis, one). The hospital stay ranged from 11 to 39 days (median 21 days). Thirty-five patients had microscopic evidence of serosal involvement (S2). Thirty-three of the patients had lymph node metastases and 17 patients had involvement of N2 nodes. Four patients had histological evidence of residual suture line tumour, but only two of these returned with recurrence at the anastomosis. Follow-up (median 3 years) revealed that splenic artery nodal involvement (N2) did not worsen the prognosis after radical resection. Despite a high complication rate, thoracoabdominal radical gastrectomy is associated with an acceptable perioperative mortality rate, adequate symptom palliation and encouraging medium-term survival. The left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of this tumour.     

Total gastrectomy via thoracotomy for cancer of gastric cardia and fundus. Report of 90 cases]

From 1978 through 1990, 90 total gastrectomy with esophagojejunostomy via thoracotomy were performed for the treatment of cancer of cardia or fundus of stomach. 85/90 patients were at TNM III-stage and 5/90-at IV-stage. 30-day post-resectional mortality was 1.1%. Five-year survival rate was 13.8%. 14CO2 respiratory test and clinical evaluation of 34 post-operative patients showed that total gastrectomy may decrease the incidence of positive residual cancer along the incision lines. It may also spare the patient from small-stomach syndrome. There was no statistical difference in postoperative fat absorption and digestive function between ordinary proximal subtotal gastrectomy and total gastrectomy.     

Goseki classification in adenocarcinoma of the cardia

BACKGROUND: To assess an additional prognostic value of Goseki histological classification to TNM staging system in adenocarcinoma of the cardia. METHODS: Sixty-one patients curatively resected for advanced (T2, T3 and T4) cardia cancer at the I Division of General Surgery, University of Verona were classified in four different grades according to Goseki. Survival curves were estimated with Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed by Cox regression model. c2 test was used to compare Goseki to Lauren classification and grading. After discharge from hospital all patients were followed with a mean follow-up of 39.5 months. RESULTS: Lauren classification and grading were significantly related to tubular differentiation (p<0.01). Kaplan-Meier estimates of survival showed a better 5-year outcome for tumors with good tubular differentiation (19%), even though the difference with poor tubular differentiated tumors was not statistically significant (p'0.06). Diffuse type carcinomas and tumors with poor cytological differentiation showed a worse prognosis at univariate analysis (p<0.01). Multivariate analysis showed no additional prognostic significance of any of the histological classification analyzed. Only T (p<0.02; RR 2.2; IC 1.2-4) and N (p<0.01; RR 5; IC 2.4-11) were independent prognostic factors. CONCLUSIONS: In adenocarcinoma of the cardia, Goseki classification did not add any information to Lauren classification and to TNM staging system.     

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study.

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.     

Total gastrectomy with esophagojejunostomy. Analysis of 100 consecutive patients

One hundred consecutive patients treated for gastric cancer by total gastrectomy from 1977 to 1982 at the second department of surgery of the Helsinki University Central Hospital were analyzed. The mean age of the patients was 61.5 years. Gastroscopy proved to be diagnostically superior to roentgenographic examination, particularly in cases of proximally located cancer. The mean length of postoperative hospital stay was 19.7 days, and the hospital mortality was 8 percent. Respiratory complications accounted for nearly half of the complications, and postoperative intraabdominal complications were recorded in 15 patients. Reoperation was performed on eight patients during the initial hospital stay due to complications. The results suggest that total gastrectomy is a safe procedure with an acceptable mortality rate, and it can be recommended both as a curative and a palliative operation in patients with gastric cancer.