Clinical efficacy of different surgical approaches in the treatment of Siewert type Ⅱ adenocarcinoma of esophagogastric junction: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To compare the clinical efficacy of different surgical approaches for Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG). Methods    The clinical data of the patients with Siewert type Ⅱ AEG who received sugeries in the Department of Thoracic Surgery of Gansu Provincial People's Hospital from August 2014 to December 2019 were retrospectively analyzed. The patients were divided into two groups according to the surgical approach: a transabdominal group (transabdominal diaphragmatic esophageal hiatus approach) and a combined group (thoracoabdominal combined with right thoracic approach). Perioperative clinical data and postoperative follow-up data were collected to compare the short- and long-term efficacy of the two groups. Results     A total of 87 patients were enrolled. There were 48 patients (31 males and 17 females, with an average age of 60.85±8.47 years) in the transabdominal group, and 39 patients (25 males and 14 females, with an average age of 61.13±8.51 years) in the combined group. There was no statistical difference between the two groups in the baseline indicators such as gender, age, tumor size and stage (P>0.05). Compared with the combined group, the operation time, intraoperative blood loss, postoperative bed rest time, postoperative total drainage volume were shorter or less, and the visual analogue scale score on the 3rd day after surgery were lower in the transabdominal group (P<0.05). However, the total number of lymph nodes dissected, the number of thoracic lymph nodes dissected and the number of positive thoracic lymph nodes in the combined group were larger than those in the transabdominal group, and the differences were statistically significant (P=0.001). The median survival time in the combined group and transabdominal group was 25.85 months and 20.86 months, respectively. The 3-year overall survival rate of the combined group was higher than that of the transabdominal group (46.2% vs. 38.9%, χ2=5.995, P=0.014). However, there was no statistical difference between the two groups in the postoperative catheter time, esophageal and gastric resection margin distance, number of abdominal lymph nodes dissected, number of positive abdominal lymph nodes, or incidence of postoperative complications (P>0.05). Conclusion    For patients with Siewert type Ⅱ adenocarcinoma of esophagogastric junction, thoracoabdominal combined with right thoracic approach is safe and effective, and has advantages in thoracic lymph node dissection, bringing more benefits to the patients, so it is recommended to be popularized in clinical practice.

Influencing of inferior mediastinum and esophageal hiatus lymph node metastasis in Siewert type Ⅱ adenocarcinoma of esophagogastric junction invading submucosal different venous divisions of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the influencing of inferior mediastinum and esophageal hiatus lymph node metastasis by submucosal different venous divisions of esophagogastric junction (EGJ) invaded in Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective case-control study was conducted. The clinicopathological data of 547 patients with Siewert type Ⅱ AEG who were admitted to Shanxi Cancer Hospital from January 2018 to December 2021 were collected. There were 461 males and 86 females, aged 61 (range, 33?75)years. Observa-tion indicators: (1) lymph node metastasis rate in different groups; (2) influencing factors of inferior mediastinum lymph node metastasis in Siewert type Ⅱ AEG; (3) influencing factors of esophageal hiatus lymph node metastasis in Siewert type Ⅱ AEG. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Mann-Whitney U test. Count data were described as percentages or absolute numbers, and comparison between groups was conducted using the chi-square test. The univariate analysis was conducted using the corresponding statistical methods based on data type. The Logistic regression model was used for multivariate analysis. Results:(1) Lymph node metastasis rate in different groups. The lymph node metastasis rate in No. 1, 2, 3, 4sa, 4sb, 7, 8a, 9, 11,20, 108, 110 of the 547 patients was 17.37%(95/547), 6.76%(37/547), 46.44%(254/547), 1.65%(9/547), 1.10%(6/547), 23.22%(127/547), 4.39%(24/547), 3.11%(17/547), 3.47%(19/547), 3.66%(20/547), 0.55%(3/547), 4.20%(23/547), respectively. Of the 547 patients, there were 456 cases with proximal of AEG invading submucosal palisade venous of EGJ including 4 cases with inferior mediastinum lymph node metastasis and no case with media mediastinum or up media-stinum lymph node metastasis. There were 91 cases with proximal of AEG invading submucosal perforator venous of EGJ including 18 cases with inferior mediastinum lymph node metastasis, 3 cases with media mediastinum lymph node metastasis and no case with up mediastinum lymph node metastasis. (2) Influencing factors of inferior mediastinum lymph node metastasis in Siewert type Ⅱ AEG. Results of multivariate analysis showed that age, tumor invading submucosal perforator venous of EGJ and histological classification were independent influencing factors for inferior media-stinum lymph node metastasis of Siewert type Ⅱ AEG ( odds ratio=0.93, 23.33, 0.31, 95% confidence interval as 0.87?0.99, 4.18?130.28, 0.12?0.78, P<0.05). (3) Influencing factors of esophageal hiatus lymph node metastasis in Siewert type Ⅱ AEG. Tumor invading submucosal perforator venous of EGJ was an independent influencing factor for esophageal hiatus lymph node metastasis of Siewert type Ⅱ AEG ( odds ratio=14.95, 95% confidence interval as 2.46?90.76, P<0.05). Conclusion:Age, tumor invading submucosal perforator venous of EGJ and histological classification are independent influencing factors for inferior mediastinum lymph node metastasis of Siewert type Ⅱ AEG, and tumor invading submucosal perforator venous of EGJ is an independent influencing factor for esophageal hiatus lymph node metastasis.

Surgical strategies for adenocarcinoma of esophagogastric junction under the era of mini-invasive surgery / 中华消化外科杂志

With the continuous update and improvement of minimally invasive techni-ques, laparoscopic and robotic surgeries have increased significantly for the surgical treatment of adenocarcinoma of esophagogastric junction (AEG). Due to the anatomical particularity and biolo-gical characteristics of Siewert type Ⅱ AEG, surgical approach, the range of resection, lymph node dissection and digestive tract reconstruction cannot be unified at present, which is also the contro-versy between gastrointestinal surgery and thoracic surgery. Laparoscopic minimally invasive techni-que may be more conducive to lower mediastinal lymph node dissection. Laparoscopic surgery of AEG after neoadjuvant chemotherapy is safe and feasible. Robotic surgery may be the direction of minimally invasive surgery in the future. The authors mainly investigate strategies of minimally invasive surgery for the surgical treatment of AEG, and look forward to more clinical trials on Siewert type Ⅱ AEG surgery to guide surgical treatment.

Analysis of influencing factors and regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the influencing factors and regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective case-control study was conducted. The clinicopatho-logical data of 185 Siewert type Ⅱ and Ⅲ AEG patients in two medical centers (113 cases in Changzhi People's Hospital Affiliated to Changzhi Medical College and 72 cases in Heji Hospital Affiliated to Changzhi Medical College) from January 2017 to January 2022 were collected. There were 143 males and 42 females, aged (64±8)years. Patients underwent radical resection of AEG combined with inferior mediastinal lymph node dissection. Observation indicators: (1) clinicopathological charac-teristics of Siewert type Ⅱ and Ⅲ AEG patients; (2) analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG; (3) regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparsion between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the rank sum test. Univariate and multivariate analyses were conducted using the Logistic regression model. Results:(1) Clinicopathological characteristics of Siewert type Ⅱ and Ⅲ AEG patients. Pathologic staging as stage Ⅰ, Ⅱ, Ⅲ and Ⅳ, degree of tumor invasion as stage T1, T2, T3 and T4, length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were found in 30, 61, 75, 7, 3, 41, 79, 50, 101, 46, 18, 8 cases of the Siewert type Ⅱ and Ⅲ AEG patients without inferior mediastinal lymph node metastasis, respectively, versus 0, 2, 10, 0, 0, 0, 5, 7, 4, 3, 2, 3 cases of the Siewert type Ⅱ and Ⅲ AEG patients with inferior mediastinal lymph node metastasis, showing a significant differences between them ( Z=?2.21, ?2.49, ?2.22, P<0.05). (2) Analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. Results of univariate analysis showed that pathological staging, depth of tumor invasion and length of esophageal invasion were related factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG ( odds ratio=2.48, 3.26, 2.03, 95% confidence intervals as 1.02?6.01, 1.21?8.80, 1.18?3.51, P<0.05). Results of multivariate analysis showed that depth of tumor invasion and length of esophageal invasion were independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG ( odds ratio=4.01, 2.26, 95% confidence interval as 1.35?11.96, 1.26?4.06, P<0.05). The inferior mediastinal lymph node metastasis probability of AEG patients with the length of esophageal invasion >3 cm and ≤4 cm was 9.47 times that of AEG patients with the length of esophageal invasion ≤1 cm. (3) Regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. The number of inferior mediastinal lymph nodes including No.110, No.111 and No.112 dissected in 185 patients of Siewert type Ⅱ and Ⅲ AEG were 127, 50 and 27. The number of lymph nodes dissected and the number of metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 69, 4, 42, 4, 4, 1, 12, 4 and 23, 0, 17, 0, 7, 2, 3, 0, respectively. There were significant differences in metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm ( χ2=8.45, 7.30, P<0.05). Of the 185 patients of Siewert type Ⅱ and Ⅲ AEG, the ratio of cases with inferior mediastinal lymph nodes metastasis was 6.49%(12/185). The ratio of inferior mediastinal lymph nodes metastasis in cases with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 3.81%(4/105), 6.12%(3/49), 10.00%(2/20), 27.27%(3/11), respectively. The ratio of No.110 lymph nodes metastasis in cases with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 2.86%(3/105), 6.12%(3/49), 5.00%(1/20), 27.27%(3/11), respectively, showing a significant difference among them ( χ2=8.26, P<0.05). Conclusions:Depth of tumor invasion and length of esophageal invasion are independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. The rate of inferior mediastinal lymph node metastasis increases with the increase of the length of esophageal invasion.

Application value of different surgical approaches in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the application value of different surgical approaches in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective cohort study was conducted. The clinicopathological data of 84 patients with Siewert Ⅱ AEG who were admitted to the Fourth Hospital of Hebei Medical University from March 2018 to March 2019 were collected. There were 65 males and 19 females, aged from 43 to 82 years, with a median age of 66 years. Of 84 patients, 24 cases undergoing radical resection of AEG via abdominal transhiatal approach (TH) were allocated into TH group, 32 cases undergoing radical resection of AEG via left thoracic approach (Sweet) were allocated into Sweet group, 28 cases undergoing radical resection of AEG via right thoracoabdominal approach (RTA) were allocated into RTA group. Observation indicators: (1) surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups; (2) postoperative complications of Siewert Ⅱ AEG patients in the 3 groups. (3) Follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect postoperative life quality, tumor recurrence and survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the ANOVA. Measurement data with skewed distribution were represented as M (range), comparison among multiple groups was analyzed using the Kruskal-Wallis H test, and comparison between two groups was analyzed using the Dunn Bonferroni test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test. Results:(1) Surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups: the operation time for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 216 minutes (range, 190-230 minutes), 174 minutes (range, 152-185 minutes) and 295 minutes (range, 261-337 minutes), respectively, showing a significant difference among the 3 groups ( H=57.977, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P<0.05). There was also a significant difference between the Sweet group and the RTA group ( P<0.05). The volume of intraoperative blood loss for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 150 mL (range, 100-163 mL), 150 mL (range, 150-200 mL) and 200 mL (range, 150-263 mL), respectively, showing a significant difference among the 3 groups ( H=11.097, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 17 (range, 10-21) and 30 (range, 24-40), respectively, showing a significant difference among the 3 groups ( H=29.775, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of thoracic lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 0, 2 (range, 1-3) and 6 (range, 3-9), respec-tively, showing a significant difference among the 3 groups ( H=48.140, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P<0.05). There was also a significant difference between the Sweet group and the RTA group ( P<0.05). The number of abdominal lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 12 (range, 8-19), and 24 (range, 17-35), respectively, showing a significant difference among the 3 groups ( H=18.149, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of positive lymph node for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 2 (range, 0-3), 0 (range, 0-3), and 5 (range, 1-6), respectively, showing a significant difference among the 3 groups ( H=7.729, P<0.05). There was no significant difference between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P>0.05). There was a significant difference between the Sweet group and the RTA group ( P<0.05). The time to postoperative first flatus of Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 3 days (range, 3-4 days), 3 days (range, 3-4 days), and 4 days (range, 3-5 days), respectively, showing no significant difference among the 3 groups ( H=3.125, P>0.05). The duration of postoperative hospital stay for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 16 days (range, 14-17 days), 14 days (range, 12-15 days), and 19 days (range, 18-21 days), respectively, showing a significant difference among the 3 groups ( H=35.244, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). (2) Postoperative complications of Siewert Ⅱ AEG patients in the 3 groups: there were 6, 6, 11 Siewert type Ⅱ AEG patients of the TH group, Sweet group and RTA group with cardiopulmonary complication, respectively, 1, 1, 2 patients with anastomotic leakage and 1, 0, 1 patients with AEG-related death, showing no significant difference in the above indicators among the 3 groups ( χ2=3.263, 0.754, 1.595, P>0.05). (3) Follow-up: 78 of 84 Siewert type Ⅱ AEG patients were followed up for 9.0 to 24.0 months, with a median follow-up time of 16.6 months. Cases with reduced respiratory function at postoperative 3 months for the TH group, Sweet group and RTA group were 4, 3, 5, respectively. Cases with gastroesophageal reflux at postoperative 3 months for the 3 groups were 3, 6, 7, respectively. Cases with weight loss at post-operative 3 months for the 3 groups were 3, 2, 4, respectively. There was no significant difference in the above indicators among the 3 groups ( χ2=1.009, 1.107, 1.112, P>0.05). Cases tumor recurrence and metastasis in the TH group, Sweet group and RTA group were 5, 7, 4, cases who survived at postoperative 1 year in the 3 groups were 19, 24, 25, respectively. There was no significant difference in the above indicators among the 3 groups ( χ2=0.897, 1.261, P>0.05). Conclusion:RTA appiled in Siewert type Ⅱ AEG patients has a longer postoperative operation time, increased intra-operative blood loss and longer hospital stay, while has better advantages in lymph node dissection.

Application value of totally laparoscopic transabdominal-hiatal approach in the radical resec-tion of Siewert type Ⅱ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective:To investigate the application value of totally laparoscopic trans-abdominal-hiatal approach in the radical resection of Siewert type Ⅱ adenocarcinoma of esophago-gastric junction (AEG).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 45 patients with Siewert type Ⅱ AEG who were admitted to the Affiliated Hangzhou First People′s Hospital, Zhejiang University School of Medicine from May 2017 to December 2020 were collected. There were 28 males and 17 females, aged from 35 to 85 years, with a median age of 64 years. All patients underwent radical resection of AEG by totally laparoscopic trans-abdominal-hiatal approach with gastrointestinal anastomosis using proximal gastrectomy with double-tract anastomosis or total gastrectomy with esophagojejunointestinal anastomosis and digestive reconstruction using transdiaphragmatic-hiatal superior overlap esophagojejunostomy. Observation indicators: (1) surgical and postoperative situations; (2) postoperative histopathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect survival of patients and tumor recurrence and metastasis up to March 2021. Measurement data with normal distribution were presented as Mean± SD and measure-ment data with skewed distribution were presented as M(range). Results:(1) Surgical and post-operative situations: all 45 patients underwent radical resection of AEG by totally laparoscopic transabdominal-hiatal approach successfully, including 35 cases undergoing total gastrectomy with esophagojejunointestinal anastomosis and 10 cases undergoing proximal gastrectomy with double-tract anastomosis. The total operation time, time of lower mediastinal lymph node dissection, time of superior overlap esophagojejunostomy, volume of intraoperative blood loss, time for initial out-of-bed activities, time to first flatus, time to initial liquid diet intake, time to drainage tube removal of the 45 patients were (235±32)minutes, (25±8)minutes, (45±10)minutes, (70±13)mL, (20±8)hours, (2.3±0.2)days, (2.6±0.8)days and (6.2±1.1)days, respectively. Eleven of 45 patients under-went postoperative complications and none of patient died during perioperative period. The post-operative duration of hospital stay of 45 patients was (10±3)days. (2) Postoperative histopatho-logical examination: all 45 patients had negative upper surgical margin. The length of proximal margin, tumor diameter, total number of lymph lodes harvested and number of lower mediastinal lymph nodes harvested were (2.5±0.5)cm, (2.9±0.8)cm, 35.0±4.0 and 2.4±0.8, respectively. Patholo-gical examination showed adenocarcinoma in all 45 patients with pTNM staging as 5 cases of stage ⅠB, 8 cases of stage ⅡA, 21 cases of stage ⅡB and 11 cases of stage ⅢA. (3) Follow-up and survival situations: 45 patients were followed up for 3 to 46 months, with a median follow-up time of 26 months. During follow-up, 8 of 45 patients died. Of the 37 patients survived, 3 cases underwent liver metastasis and 3 cases underwent bone metastasis, lung metastasis or peritoneal metastasis respec-tively.Conclusion:Total laparoscopic transabdominal-hiatal approach is safe and feasible in the treatment of Siewert type II AEG with a satisfactory clinical efficacy.

Comparison of quality of life in patients with advanced Siewert type Ⅱ adenocarcinoma of the esophagogastric junction treated by three different operations / 中国胸心血管外科临床杂志

@#Objective     To compare the quality of life (QOL) of advanced Siewert type Ⅱ adenocarcinoma esophagogastric junction (AEG) patients treated by the total gastrectomy, traditional proximal gastrectomy or proximal gastrectomy with gastric tube reconstruction opertations, and to provide some clinical basis for the choice of surgical methods for AEG. Methods     A total of 90 patients with Siewert type Ⅱ AEG were retrospectively collected from the Affiliated Hospital of North Sichuan Medical College. Patients were divided into 3 groups according to different surgical methods (n=30 in each group), a total gastrectomy group (23 males, 7 females, aged 47-79 years), a traditional proximal gastrectomy group (treated with the traditional proximal gastrectomy procedure, 19 males, 11 females, aged 44-80 years), and a narrow gastric tube group (treated with the proximal gastrectomy with gastric tube reconstruction procedure, 25 males, 5 females, aged 47-83 years). The Chinese version of Quality of Life Questionnaire Core-30 (QLQ-C30) and Quality of Life Questionnaire Oesophagogastric-25 (QLQ-OG25) designed by European Organization for Research and Treatment of Cancer (EORTC) were used to collect the patients’ information in the three groups about their QOL during the first six months and one year after the three procedures. Results     There was no statistical difference in the clinical data among the three groups (all P>0.05). QOL during the first six months after the operations assessed by the QLQ-C30 questionnaire table showed that the narrow gastric tube group was significantly best in total QOL, physical function, fatigue, and emotional function among the three groups (all P<0.05). The total gastrectomy group was the worst in role function, dyspnea, fatigue and diarrhea among the three groups (all P<0.05). The traditional proximal gastrectomy group had a worse evaluation in lose of appetite than the other two groups (P<0.05). QOL during the first six months after the operations assessed by the QLQ-OG25 questionnaire table showed that the traditional proximal gastrectomy group had a significantly worse evaluation in palirrhea than the other two groups (both P<0.05). The total gastrectomy group had a significantly worse evaluation in anxiety than the other two groups (both P<0.05). QOL during the first year after the operations assessed by the QLQ-C30 questionnaire table showed that the narrow gastric tube group had a significantly highest evaluation in total QOL physical function and emotional function among the three groups (all P<0.05). The total gastrectomy group had a significantly worst evaluation in diarrhea among the three groups (P<0.05). QOL during the first year after operations assessed by QLQ-OG25 questionnaire table showed that the traditional proximal gastrectomy group had a significantly worse evaluation in palirrhea than the other two groups (all P<0.05). Conclusion     The narrow tubular esophagogastric anastomosis is better than the total gastrectomy and the traditional proximal gastrectomy for the treatment of the advanced Siewert type Ⅱ adenocarcinoma of esophagogastric junction, so this operation is worth being recommended.

Application value of totally laparoscopic transabdominal-hiatal approach in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction / 中华消化外科杂志

Objective To investigate the safety and feasibility of totally laparoscopic transabdominalhiatal approach in the treatment of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 11 patients with Siewert type Ⅱ AEG who were admitted to Affiliated Hangzhou First People's Hospital of Zhejiang University School of Medicine from May 2017 to July 2018 were collected.There were 8 males and 3 females,aged 56-72 years,with an average age of 63 years.Patients underwent radical resection of AEG by totally laparoscopic transabdominalhiatal approach.Observation indicators:(1) surgical situations and postoperative recovery;(2) postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant chemotherapy,complications,food intake,anastomosis patency,tumor recurrence and metastasis,and survival up to December 2018.Measurement data with normal distribution were presented as Mean±SD,measurement data with skewed distribution were presented as M (range),and count data were represented as absolute number or percentage.Results (1) Surgical situations and postoperative recovery:all the patients underwent totally laparoscopic radical resection of Siewert type Ⅱ AEG by transabdominal-hiatal approach,without conversion to open surgery or perioperative death.Of the 11 patients,8 underwent total gastrectony including 3 combined with splenic hilar lymph node dissection and 3 underwent proximal gastrectomy with double-tract reconstruction.Operation time,time of superior overlap esophagojejunostomy,volume of intraoperative blood loss,time for initial out-of-bed activities,time to first flatus,time to initial liquid diet intake,time of drainage tube removal were respectively (245± 39)minutes,(60± 12) minutes,(75±23) mL,(24± 8) hours,(2.4± 0.5) days,(3.5 ± 0.8) days,(8.2 ± 1.3) days respectively.There was no serious complication including postoperative hemorrhage,anatomotic fistula or death.Three patients had left pleural effusion,and were cured after thoracic drainage.The duration of postoperative hospital stay was (11.0±3.0) days.(2) Postoperative pathological examination:all the 11 patients had negative upper surgical margin.The length of proximal margin,tumor diameter,total number of lymph lodes harvested,and number of lower mediastinal lymph lodes harvested were (2.1 ±0.2) cm,(2.6±0.9) cm,(36.0±4.0)/case and (2.3± 0.8)/case.Pathological examination showed adenocarcinoma in all the 11 patients.pTNM staging:2 cases were in stage Ⅰ B,4 cases in stage Ⅱ A,3 cases in stage Ⅱ B and 2 cases in stage Ⅲ A.(3) Follow-up and survival situations:11 patients were follow-up for 6-19 months,with a median time of 9 months.Chemotherapy regimeus were formulated according to the pathological examination.Nine patients received postoperative adjuvant chemotherapy,and 2 in stage Ⅱ B received no postoperative adjuvant chemotherapy.During the follow-up,11 patients had no obvious reflux symptom or choking feeling,and the anastomosis was patent as evaluated by oral contrast agent and gastroscopy.There was no tumor recurrence and metastasis or death in the 11 patients.Conclusion Totally laparoscopic transabdominal-hiatal approach applied in the radical resection is safe and feasible for the treatment of Siewert type Ⅱ AEG,with good short-term outcomes.

Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction: a prospective randomized controlled study / 中华消化外科杂志

Objective To investigate the clinical efficacy of jejunal interposed single-tract and doubletract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG).Methods The prospective study was conducted.The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected.All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table,including patients using single-tract jejunal interposition reconstruction in the single-tract group and patients using double-tract jejunal interposition reconstruction in the double-tract group.Digestive tract reconstruction:after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum,single-tract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma,and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the single-tract group.Patients in the double-tract group used the same digestive tract reconstruction,but jejunum was not ligated.The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy.Observation indicators:(1) intra-and post-operative situations;(2) follow-up situations.Follow-up using telephone interview was performed to detect postoperative complication,gastrointestinal function and body mass index (BMI) up to November 2017.Measurement data with normal distribution were represented as-x± s and comparison between groups was analyzed using t test.Measurement data with skewed distribution were described as M (range),and comparison between groups was analyzed using the nonparametric test.Repeated measurement data were analyzed by the repeated measures ANOVA.Comparisons of count data were done using chi-square test.Ordinal data were analyzed by the Kruskal Wallis H test.Results One hundred and eight patients were screened for eligibility,including 55 in the single-tract group and 53 in the double-tract group.(1) Intra-and post-operative situations:total operation time,digestive tract reconstruction time,volume of intraoperative blood loss,time to initial anal exsufflation,postoperative complications,cases with gastroesophageal reflux,intestinal obstruction and Visick grading ＞ Ⅱ and duration of postoperative hospital stay were respectively (145±26) minutes,(30±6) minutes,(181±37) mL,(53± 16) hours,1,1,1,(10.0±2.4) days in the singletract group and (139±29)minutes,(26±3)minutes,(176±31)mL,(50±17) hours,3,0,3,(9.4±l.4)days in the double-tract group,with no statistically significant difference between groups (t =0.725,0.219,0.162,-0.576,x2 =2.960,5.830,t =-0.993,P＞0.05).Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks,and were improved by symptomatic treatment such as increasing the solid food intake.One patient in the single-tract group had internal hernia-induced intestinal obstruction and was cured by reoperation.There was no anastomotic leakage,bleeding,infection,dumping syndrome and gallstone between groups.Of 108 patients,71 underwent 6-cycle SOX chemotherapy,including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall.(2) Follow-up situations:108 patients were followed up for 12.0-48.0 months,with a median time of 28.6 months.During the follow-up,bowel sound in the double-tract group and single-tract group was 8 times / minute (range,5-12 times / minute) and 3 times /minute (range,2-5 times/ minute),with a statistically significant difference between groups (Z=-0.692,P＜0.05).The single food intake,serum gastrin level,ratio of serum pepsinogen Ⅰ and Ⅱ levels and BMI from preoperation to postoperative 12 months were from (1 117± 129)mL to (817± 127)mL,from (12±5)pmol/L to (41±13) pmol/L,from 11.3±2.8 to 5.1±2.2,(65±7)kg to (63±5) kg in the single-tract group and from (1 095±118)mL to (783±80)mL,from (10±4)pmol/L to (40±10)pmol/L,from 12.4±2.9 to 4.2±1.3,from (63±6) kg to (58±6)kg in the double-tract group,respectively,with no statistically significant difference in single food intake,serum gastrin level and ratio of serum pepsinogen Ⅰ and Ⅱ levels between groups (F =0.468,0.108,0.161,P＞0.05).There was a statistically significant difference in changing trend of BMI between groups (F=24.930,P＜0.05).Conclusion Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don't affect secretion function of gastric remnant,but there are frequent bowel sounds and obvious weight loss.

Lymph node dissection for Siewert Ⅱ esophagogastric junction adenocarcinoma: a retrospective study of three surgical procedures / 中华胸心血管外科杂志

Objective The surgical approaches and extent of lymph node dissection for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are controversial.The present study was aimed to investigate the application of right thansthoracic Ivor-Lewis(IL),left transthoracic(LTT),and left thoracoabdominal(LTA) approach in Siewert type Ⅱ AEG.Methods The data of 196 patients with Siewert type Ⅱ AEG received surgical resection in our cancer center between January 2014 and April 2016 was retrospectively analyzed.Finally,136 patients met the inclusion criteria were enrolled in the study and divided into the IL(47 cases),LTT(51 cases),and LTA group(38 cases).Clinical and short-term treatment effects were compared among the three groups.Results The patients with weight loss,diabetes,and heart disease increased in the LTT group (P =0.054,P =0.075,and P =0.063,respectively).Operation time was significantly longest in the IL group (P =0.000),but the amount of bleeding and tumor size did not significantly differ among the three groups (P =0.176 and P =0.228,respectively).The IL group had the significantly longest proximal surgical margin (P =0.000) and most number of total (P =0.000) and thoracic lymph nodes(P =0.000) dissected.Both the IL and LTA groups had more abdominal lymph nodes dissected than the LTT group(P =0.000).In general,the IL and LTT group had the highest dissection rates of every station of thoracic (P ＜ 0.05) and lower mediastinal lymph nodes (P ＜ 0.05),respectively.The dissection rate of the paracardial,left gastric artery,and gastric lesser curvature lymph nodes did not differ significantly among the three groups(P ＞ 0.05),but the dissection rate of the hepatic artery,splenic artery,and celiac trunk lymph nodes was significantly highest in the IL group (P ＜0.05).Postoperative hospital stay,perioperative complications,and mortality did not differ significantly among the three groups(P ＞ 0.05).Conclusion Compared with the traditional left transthoracic approach,the Ivor-Lewis approach did not increase the perioperative mortality and complication rates in Siewert type Ⅱ AEG,but obtained satisfactory length of the proximal surgical margin,and was better than left transthoracic approach in thoracic and abdominal lymph node dissection.However,the advantages of Ivor-Lewis procedure requires further follow-up and validation through prospective randomized controlled trials.

Comparison of the effect of lymph node dissection performed by Ivor-Lewis or left-sided thoracic esophagogastrectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction / 中华肿瘤杂志

Objective@#To compare the extent of lymphadenectomy and postoperative complications between Ivor-Lewis procedure and left sided thoracotomy in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (AEG).@*Methods@#The clinical data of 101 patients with Siewert type Ⅱ EG who received surgical treatment between January 2014 and September 2015 in the Department of Esophageal Cancer, Tianjin Medical University Cancer Hospital were analyzed retrospectively. These patients were divided into Ivor-Lewis group (IL, n=38) and left- sided thoracotomy group (LT, n=63) according to the operation mode. The number and extent of dissected lymph nodes and postoperative complications were compared between the two groups.@*Results@#The surgical blood loss, length of postoperative stay, anastomotic leakage, pulmonary infection, respiratory failure and complications of incision of the two groups showed no significant differences (P>0.05 of all). The operation time of IL group was 200 min, significantly longer than the LT group (120 min, P<0.05). The number of resected lymph nodes in the IL and LT groups were (20±9) and (13±7), respectively, with a statistically significant difference (P<0.001). Significantly more thoracic lymph nodes (7±5) were harvested in the IL group than in the LT group (2±2, P<0.001), and the number of resected abdominal lymph nodes in the IL and LT groups were (13±8) and (11±7), with a non-significant difference (P=0.157). As regarding the lymph node dissection rate, the IL approach was obviously better than the LT approach in the following lymph node stations: superior mediastinal nodes, subcarinal nodes, left hilar nodes, right hilar nodes, middle thoracic paraesophageal nodes, lower thoracic paraesophageal nodes, lymph nodes along the common hepatic artery, and lymph nodes along the splenic artery(P<0.05 for all).@*Conclusions@#The Ivor-Lewis procedure achieves better thoracic and abdominal lymph node dissection, and does not cause more postoperative complications than the left-sided thoracotomy in patients with Siewert type Ⅱ AEG. However, these findings need to be confirmed by large-scale randomized clinical trial in the future.

Application value of the curved cutter stapler device combined with trans-orally inserted anvil in the radical resection of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction / 中华消化外科杂志

Objective To investigate the application value of the curved cutter stapler device combined with trans-orally inserted anvil (OrVil) in the radical resection of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (AEG).Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 206 patients with Siewert type Ⅱ AEG who were admitted to the Henan Tumor Hospital between March 2011 and March 2016 were collected.All the 206 patients underwent radical resection and 3-step clock wise total gastrectomy + D2 lymph node dissection.Observation indicators:(1) surgery and postoperative recovery situations:surgical approach,overall operation time,hammer anvil placing time,esophagojejunal anastomosis time,volume of intraoperative blood loss,number of lymph node dissected,time to anal exsufflation,postoperative complications and duration of postoperative hospital stay;(2) postoperative pathological examination and chemotherapy;(3) follow-up and survival situations.Follow-up using telephone interview and outpatient examination was performed to detect tumor-free survival of patients up to April 2016.Measurement data with normal distribution were represented as x±s.The survival rate was calculated by the Kaplan-Meier method.Results (1) Surgery and postoperative recovery situations:all the 206 patients received successful operations,including 85 with abdominal operation,50 with abdominal incision through the diaphragmatic muscle into thoracic surgery and 71 with thoracic-abdominal surgery.Overall operation time,hammer anvil placing time,esophagojejunal anastomosis time,volume of intraoperative blood loss,number of lymph node dissected,time to anal exsufflation and duration of hospital stay were (113.7± 15.4)minutes,(3.5± 1.2)minutes,(10.4±2.9)minutes,(128±25) mL,32± 6,(2.4 ± 0.9) days and (12.3 ± 1.9) days,respectively.Of 206 patients,15 with postoperative complications were cured by conservative treatment,including 6 with implicit anastomotic fistula,3 with dominant anastomotic fistula,2 with pancreatic leakage,2 with intestinal obstruction,1 with anastomotic stenosis and 1 with thoracic and abdominal infection.There was no reoperation due to perioperative complications.(2) Postoperative pathological examination and chemotherapy:postoperative pathological results showed that distance from resection margin of the esophagus to tumor was (5.2±0.4) cm,without cancer cells in the resection margin.Among 206 patients,171 received postoperative chemotherapy by S1 single agent combined with oxaliplatin for 6-8 cycles or oral S1 single agent for 1 year.(3) Follow-up and survival situations:206 patients were followed up for (2.7± 0.3)years,with a tumor-free 3-year survival rate of 58％.During the follow-up,there was no recurrent anastomotic tumor.Conclusion The curved cutter stapler device combined with OrVil in the radical resection of Siewert type Ⅱ AEG can simplify the difficulty of esophagojejunal anastomosis and guarantee the safe resection margin of the lower esophagus.