Transthoracic Approach vs Transhiatal-Abdominal Approach in the Treatment of Locally Advanced Siewert Type II Esophagogastric Junctional Adenocarcinoma: A Retrospective Study

Abstract

Background The surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction still remains controversial. This study aims to compare the differences between transthoracic approach and transhiatal-abdominal approach.Methods Patients with Siewert type II adenocarcinoma of the esophagogastric junction underwent surgery from January 2010 to July 2015 were analyzed retrospectively. They were divided into transthoracic approach group and transhiatal-abdominal approach group. Postoperative complications, surgical characteristics and 5-year survival rates of the two groups were compared by Chi-square test and log-rank test respectively, and the extent of gastrectomy was analyzed in subgroups. Finally, Cox univariate and multivariate analyses were conducted to predict the independent prognostic factors for long-term survival.Result A total of 255 patients with Siewert type II adenocarcinoma of the esophagogastric junction were analyzed, 143 with transthoracic approach group, 112 with transhiatal-abdominal approach group and the 5-year survival rate was 37.8% and 40.2% respectively (P=0.575). The incidence of positive proximal margins (0.70% vs. 6.25%, P=0.023) and intraoperative bleeding volume (175.15 ± 110.44 vs. 206.57 ± 131.97 ml, P=0.046) in transthoracic approach group were lower. Transhiatal-abdominal approach group had fewer pulmonary infection (8.04% vs. 17.48%, P=0.028) and shorter hospitalization time (11.32 vs. 12.67 days, P=0.008). In subgroup analysis, the 5-year survival rate of patients treated with partial gastrectomy was better than that of patients treated with total gastrectomy (44.8% vs. 36.1%, P=0.038). Conclusion Our study shows no significant difference between the two groups with regard to long-term survival. The transthoracic approach had more advantages for proximal margin and mediastinal lymph node dissection, while the transabdominal approach had less trauma to patients. Partial gastrectomy may be sufficient for patients with locally advanced disease. T stage and N stage were independent risk factors for long-term survival.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

“…Ultimately, 17 articles 1,7,[35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] were included in the final qualitative and quantitative synthesis of 15297 patients undergoing curative resection for AEJ Siewert II. Of the 17 studies deemed suitable for analysis, only two were RCTs.…”

“…41 Most non RCTs were at a moderate risk of bias when evaluated according to ROBINS-I, as shown in Annex 1b. Six studies 1,35,39,42,43,46 had a high risk and eight had moderate risk. 7,[36][37][38]40,44,47,48…”

“…of dissected lymph nodes. Eight studies 1,7,40,42,44,46,47,49 reported data on number of dissected lymph nodes (Figure 2). We found no statistically significant mean difference between TTA and TAA (MD = −2.17, 95% CI [−4.43, 0.09], p = 0.06).…”

“…Post-operative outcomes. Mortality: This criterion was reported in nine included studies 7,35,36,38,40,42,43,47,49 including 2012 patients in the TTA group and 4804 patients in the TAA group (Figure 3). There was no significant difference between the two groups (OR = 0.83, 95% CI [0.62, 1.12], p = 0.23) with low heterogeneity (I 2 = 19%).…”

“…Overall morbidity: Ten articles 1,7,35,36,[42][43][44]46,47,49 reported data on perioperative morbidity rate. We observed lower morbidity rate in the TAA group (37.2% vs 28%).…”