The surgical procedure for esophagogastric junction cancer — discussing the tactics

Abstract

Introduction. Currently, there is no standardized surgical tactics for the esophagogastric junction cancer treatment. The issues of the resection margin, volume of lymphodissection and the optimal size of the gastric stump are still being discussed. This article analyzes the influence of these parameters on the recurrence-free survival and postoperative quality of life for patients, according to the literature data.
 Objective. Analysis of the treatment outcomes for patients with esophagogastric junction cancer, depending on the surgical tactics.
 Materials and Methods. The article analyzes the literature data evaluating various approaches in the surgical treatment of esophagogastric junction cancer. We present an example (from the Yasuyuki Seto study) of a patient with proximal gastric adenocarcinoma with a depth of T3 invasion and the surgical tactics regarding the size of the gastric stump. a A great advantage of the resection margin located at 2 cm from the proximal margin and at 5 cm from the distal margin has been shown. According to the results of our own observations, a patient with proximal gastric adenocarcinoma with an invasion depth of T3 underwent a resection with the proximal and distal resection margins of 13 and 65 mm, respectively. Negative resection margins were diagnosed intraoperatively. The patient's recurrence -free survival was 6 years. A total gastrectomy or esophagectomy are not the operations of choice because of the worsening of the patient's quality of life. When analyzing the depth of invasion according to the literature data, it has been found that an invasion in the esophagus of more than 30 mm is associated with an increased risk of metastatic lymph nodes of the superior and middle mediastinum. With a gastric invasion length of more than 40 mm, lymph nodes of lesser curvature along the right gastric artery are affected. According to the literature, a gastric stump with the size of more than two-thirds of the organ size was favorable in terms of the postoperative quality of life. Many authors indicate the positive effect of maintaining the gastroesophageal sphincter and cardia of the stomach. In the study by Yasuyuki Seto, proximal gastric resection was applied only if it was possible to maintain more than 12 cm in the small curvature and 25 cm in the large curvature.
 Conclusion. When choosing the surgical tactics for the esophagogastric junction cancer, one needs to focus on the patient's quality of life after the surgery. It is necessary to achieve negative resection margins in each case. The resection margins should be more than 2 and 5 cm for the proximal and distal margins, respectively. Dissection of the lymph nodes of the middle and superior mediastinum should be carried out with invasion of the tumor into the esophagus by more than 30 mm, removal of the lymph nodes of the lesser curvature of the stomach along the right gastric artery must be carried out if the tumor invasion into stomach is more than 40 mm. It is optimal to keep the gastric stump equal to two-thirds of the size of the organ. The issue of the surgical tactics in cancer of the esophageal-gastric transition is of great practical importance and requires a further study.