Objective: To evaluate the effects on short-term clinical outcomes and long-term quality of life of laparoscopic-assisted radical proximal gastrectomy with esophageal gastric tube anastomosis versus total gastrectomy with Roux-en-Y anastomosis for adenocarcinoma of the esophagogastric junction. Methods: This was a propensity score matching, retrospective, cohort study. Clinicopathological data of 184 patients with adenocarcinoma of the esophagogastric junction admitted to two medical centers in China from January 2016 to January 2021 were collected (147 in the First Affiliated Hospital of Xiamen University and 37 in the Affiliated Hospital of Qinghai University). All patients had undergone laparoscopic-assisted radical gastrectomy. They were divided into two groups based on the extent of tumor resection and technique used for digestive tract reconstruction. A proximal gastrectomy with reconstruction by esophageal gastric tube anastomosis group comprised 82 patients and a total gastrectomy with reconstruction by Roux-en-Y anastomosis group comprised 102 patients. These groups differed significantly in the following baseline characteristics: age, preoperative hemoglobin, preoperative albumin, tumor length, tumor differentiation, and tumor TNM stage (all P<0.05). To eliminate potential bias caused by unequal distribution between the two groups, 1∶1 matching was performed by the nearest neighbor matching method. The 13 matched variables comprised sex, age, height, body mass, body mass index, preoperative glucose, preoperative hemoglobin, preoperative total protein, preoperative albumin, neoadjuvant radiotherapy, tumor length, degree of differentiation, and pathological TNM stage. Postoperative complications, postoperative nutritional status, incidence of reflux esophagitis 1 year after surgery, and quality of life were compared between the two groups. Results: After propensity score matching, 60 patients each were enrolled in the proximal gastrectomy with esophageal gastric tube anastomosis and total gastrectomy with Roux-en-Y anastomosis groups. The baseline characteristics were comparable between these groups (all P>0.05). There were no significant differences between the two groups in operative time, intraoperative bleeding, time to semifluid diet, postoperative hospital days, tumor length, and total hospital costs (P>0.05). Patients in the proximal gastrectomy with esophageal gastric tube anastomosis group had earlier postoperative gastric tube and abdominal drainage tube removal time than those in the total gastrectomy with Roux-en-Y anastomosis group (t=-2.183, P=0.023 and t=-4.073, P<0.001, respectively). In contrast, significantly fewer lymph nodes were cleared and significantly fewer lymph nodes were positive in the proximal gastrectomy with esophageal gastric tube anastomosis group than in the total gastrectomy with Roux-en-Y anastomosis group (t=-5.754, P<0.001 and t=-2.575, P=0.031, respectively). The incidence of early postoperative complications was 43.3% (26/60) in the total gastrectomy with Roux-en-Y anastomosis group; this is not significantly higher than the 26.7% (16/60) in the proximal gastrectomy with esophageal gastric tube anastomosis group (χ²=3.663，P=0.056). The incidences of pulmonary infection (31.7%, 19/60) and pleural effusion (30.0%, 18/60) were significantly higher in the total gastrectomy with Roux-en-Y anastomosis group than in the proximal gastrectomy with esophageal gastric tube anastomosis group (13.3%, 8/60 and 8.3%, 5/60, respectively); these differences are significant (χ²=8.711, P=0.003 and χ²=11.368, P=0.001, respectively). All early complications were successfully treated before discharge. The incidence of long-term postoperative complications was 20.0% (12/60) in the total gastrectomy with Roux-en-Y anastomosis group and 35.0% (21/60) in the proximal gastrectomy with esophageal gastric tube anastomosis group; this difference is not significant (χ²=3.386，P=0.066). The incidence of reflux esophagitis was 23.3% (14/60) in the proximal gastrectomy with esophageal gastric tube anastomosis group; this is significantly higher than the 1.7% (1/60) in the total gastrectomy with Roux-en-Y anastomosis group (χ²=12.876, P<0.001). Body mass index had decreased significantly in both groups 1 year after surgery compared with preoperatively; however, the difference between the two groups was not significant (P>0.05). The differences in hemoglobin and albumin concentrations between 1 year postoperatively and preoperatively were not significant (both P>0.05). Quality of life was assessed using the Visick grade. Visick grade I dominated in both groups. The percentage of patients with Visick II and III in the total gastrectomy with Roux-en-Y anastomosis group was 11.7% (7/60), which is significantly lower than the 33.3% (20/60) in the proximal gastrectomy with esophageal gastric tube anastomosis group (χ²=8.076, P=0.004). No patients in either group had a grade IV quality of life. Conclusions: Both proximal gastrectomy with esophageal gastric tube anastomosis and total gastrectomy with Roux-en-Y anastomosis laparoscopic-assisted radical surgery for adenocarcinoma of the esophagogastric junction are safe and feasible. However, both procedures have their own advantages and disadvantages in terms of postoperative complications. The incidence of reflux esophagitis is higher after proximal gastrectomy with esophageal gastric tube anastomosis, whereas the long-term quality of life is lower than that of patients after total gastrectomy with Roux-en-Y anastomosis.
Humans ; Anastomosis, Roux-en-Y ; Retrospective Studies ; Cohort Studies ; Esophagitis, Peptic ; Quality of Life ; Propensity Score ; Gastrectomy/methods* ; Esophagogastric Junction/surgery* ; Anastomosis, Surgical/methods* ; Adenocarcinoma/pathology* ; Stomach Neoplasms/pathology* ; Postoperative Complications ; Treatment Outcome

Objective: We aimed to explore the feasibility of a single-port thoracoscopy- assisted five-step laparoscopic procedure via transabdominal diaphragmatic(TD) approach(abbreviated as five-step maneuver) for No.111 lymphadenectomy in patients with Siewert type II esophageal gastric junction adenocarcinoma (AEG). Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) age 18-80 years; (2) diagnosis of Siewert type II AEG; (3) clinical tumor stage cT2-4aNanyM0; (4) meeting indications of the transthoracic single-port assisted laparoscopic five-step procedure incorporating lower mediastinal lymph node dissection via a TD approach; (5) Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1; and (6) American Society of Anesthesiologists classification I, II, or III. The exclusion criteria included previous esophageal or gastric surgery, other cancers within the previous 5 years, pregnancy or lactation, and serious medical conditions. We retrospectively collected and analyzed the clinical data of 17 patients (age [mean ± SD], [63.6±11.9] years; and 12 men) who met the inclusion criteria in the Guangdong Provincial Hospital of Chinese Medicine from January 2022 to September 2022. No.111 lymphadenectomy was performed using five-step maneuver as follows: superior to the diaphragm, starting caudad to the pericardium, along the direction of the cardio-phrenic angle and ending at the upper part of the cardio-phrenic angle, right to the right pleura and left to the fibrous pericardium , completely exposing the cardio-phrenic angle. The primary outcome includes the numbers of harvested and of positive No.111 lymph nodes. Results: Seventeen patients (3 proximal gastrectomy and 14 total gastrectomy) had undergone the five-step maneuver including lower mediastinal lymphadenectomy without conversion to laparotomy or thoracotomy and all had achieved R0 resection with no perioperative deaths. The total operative time was (268.2±32.9) minutes, and the lower mediastinal lymph node dissection time was (34.0±6.0) minutes. The median estimated blood loss was 50 (20-350) ml. A median of 7 (2-17) mediastinal lymph nodes and 2(0-6) No. 111 lymph nodes were harvested. No. 111 lymph node metastasis was identified in 1 patient. The time to first flatus occurred 3 (2-4) days postoperatively and thoracic drainage was used for 7 (4-15) days. The median postoperative hospital stay was 9 (6-16) days. One patient had a chylous fistula that resolved with conservative treatment. No serious complications occurred in any patient. Conclusion: The single-port thoracoscopy-assisted five-step laparoscopic procedure via a TD approach can facilitate No. 111 lymphadenectomy with few complications.
Male ; Female ; Humans ; Adolescent ; Young Adult ; Adult ; Middle Aged ; Aged ; Aged, 80 and over ; Diaphragm/surgery* ; Retrospective Studies ; Feasibility Studies ; Esophagogastric Junction/surgery* ; Lymph Node Excision/methods* ; Stomach Neoplasms/pathology* ; Laparoscopy/methods* ; Gastrectomy/methods* ; Esophageal Neoplasms/pathology* ; Adenocarcinoma/pathology* ; Thoracoscopy

The electrophysiological activity of the gastrointestinal tract and the mechanical anti-reflux structure of the gastroesophageal junction are the basis of the anti-reflux function of the stomach. Proximal gastrectomy destroys the mechanical structure and normal electrophysiological channels of the anti-reflux. Therefore, the residual gastric function is disordered. Moreover, gastroesophageal reflux is one of the most serious complications. The emergence of various types of anti-reflux surgery through the mechanism of reconstructing mechanical anti-reflux barrier and establishing buffer zone, and the preservation of, the pacing area and vagus nerve of the stomach, the continuity of the jejunal bowel, the original gastroenteric electrophysiological activity of the gastrointestinal tract, and the physiological function of the pyloric sphincter, are all important measures for gastric conservative operations. There are many types of reconstructive approaches after proximal gastrectomy. The design based on the anti-reflux mechanism and the functional reconstruction of mechanical barrier, and the protection of gastrointestinal electrophysiological activities are important considerations for the selected of reconstructive approaches after proximal gastrectomy. In clinical practice, we should consider the principle of individualization and the safety of radical resection of tumor to select a rational reconstructive approaches after proximal gastrectomy.
Humans ; Stomach Neoplasms/surgery* ; Gastrectomy ; Gastroesophageal Reflux ; Esophagogastric Junction/surgery* ; Pylorus/pathology*

There are several controversies and issues in the surgical treatment of esophagogastric junction (AEG) currently. The Siewert classification and TNM staging system are commonly used to assist clinical decision and prognosis prediction. Generally, transthoracic procedure is more suitable for Siewert Ⅰ type and longer esophageal invasion patients, while transhiatal is more suitable for Siewert Ⅲ type patients. The optimal extent of lymph node dissection for AEG should be based on tumor location and esophageal invasion range. The extent of surgical resection and the method of digestive tract reconstruction should be based on the principle of radical resection and surgical safety, and the postoperative life quality of patients should be fully considered. Roux-en-Y anastomosis is the most common and efficient anastomosis after total gastrectomy, while double tract anastomosis is recommended by many experts after proximal gastrectomy. With the continuous advancement of minimally invasive techniques, experienced centers and teams can perform digestive tract reconstruction under total laparoscopy. In the future, more high-quality studies are expected to provide evidence-based medical evidence for AEG's surgical treatment decisions.
Adenocarcinoma/surgery* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Gastrectomy/methods* ; Humans ; Stomach Neoplasms/surgery*

In recent years, adenocarcinoma of esophagogastric junction (AEG) has received increased attention from the academic community. However, the esophagogastric junction (EGJ) straddles two anatomical regions: the thoracic cavity and the abdominal cavity. The histological features of the EGJ are different from those of the esophagus and stomach. There are general disagreements among the related disciplines regarding the definition and classification of AEG. By summarizing the views of different disciplines, including endoscopy, radiography, and pathology, a more comprehensive definition of the EGJ was formulated in the Japanese Classification of Gastric Carcinoma (the 15th edition), and the principle of endoscopic diagnostic priority was established. In recent years, with the development of physiological and anatomical studies, the EGJ has gradually expanded conceptually into a complex functional anatomical region covering the distal esophagus to the proximal stomach. The venous and lymphatic vessels in the EGJ are characterized by bidirectional flow, which is an important anatomical basis for the invasion and metastasis patterns of tumors in this region. The clinical practice of EGJ cancer has been promoted by the creation of Nishi and Siewert classification systems. With the support of a series of clinical studies for its scientificity and effectiveness, the Siewert classification is widely accepted by the international community, and successively introduced into major international practice guidelines. In general, the staging and management of Siewert Ⅰ and Ⅱ AEG are recommended as esophageal cancer, while Siewert Ⅲ AEG is recommended for gastric cancer. However, in the Japanese guidelines for the treatment of esophageal and gastric cancers, the Nishi classification is still used to define and classify EGJ cancer. Recent year, a Chinese consensus on the surgical treatment of AEG was formulated by multidisciplinary experts. The main controversies were summarized in the consensus, and proposals that incorporate the domestic situation were also presented. At present, only by returning to the basic anatomical and physiological perspectives, strengthening multidisciplinary communication and cooperation, and with the help of emerging bioinformatics, digital, and material technology, can it be possible to get out of the dilemma faced by traditional AEG classification and staging system.
Adenocarcinoma/surgery* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Humans ; Stomach Neoplasms/surgery*

Objective: To examine the long term outcome of splenic hilar lymphadenectomy (SHL) for locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG) with a tumor diameter ≥4 cm. Methods: A total of 489 locally advanced Siewert type Ⅱ and Ⅲ AEG patients with a tumor diameter ≥4 cm who underwent radical resection from January 2010 to April 2016 were included. There were 383 males and 106 females. There were 225 patients aged≥65 years and 264 patients aged <65 years. SHL was conducted in 270 patients(SHL group). Wilcoxon rank-sum test or χ² test were conducted for inter-group comparison. Cox proportional hazard regression was used to analyze the long term outcome of SHL and the prognosis factors of overall survival. Kaplan-Meier curve was drawn finally. The results of survival analysis were verified by Log-rank test. Results: Followed-up to April 2021,the median follow-up time was 78.0 months (range: 74.0 to 85.0 months), the follow-up rate was 95.5%(467/489). The splenic hilar lymphnode metastasis rate of the SHL group was 12.6% (34/270). Younger patients (<65 years old), less complications, higher proportion of patients received adjuvant chemotherapy were demonstrated in the SHL group (χ²: 5.644 to 6.744, all P<0.05). Multivariate analysis showed that SHL was the independent prognosis factor of overall survival for patients with Siewert type Ⅱ and Ⅲ AEG and a tumor diameter≥4 cm (HR=0.68, 95%CI: 0.52 to 0.88, P=0.004) along with preoperative CA19-9, pathological T stage, pathological N stage, adjuvant chemotherapy and postoperative complication. Further subgroup analysis demonstrated that the SHL group had better 5-year overall survival than non-SHL group (62.4% vs. 39.2%, χ²=17.983, P=0.006) in Siewert type Ⅲ AEG rather than in Siewert type Ⅱ AEG(57.3% vs. 53.7%, χ²=3.031, P=0.805). Conclusion: In experienced center, splenic hilar lymphadenectomy can improve the prognosis of Siewert type Ⅲ AEG with a tumor diameter ≥4 cm.
Adenocarcinoma/surgery* ; Aged ; Esophageal Neoplasms ; Esophagogastric Junction/surgery* ; Female ; Humans ; Lymph Node Excision/methods* ; Lymphatic Metastasis/pathology* ; Male ; Retrospective Studies ; Stomach Neoplasms/surgery* ; Survival Analysis

The incidence of Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is increasing year by year. Due to its special anatomical location and biological behavior, the treatment of AEG is still controversial in terms of lymph node dissection, the esophageal resection margin, range of gastrectomy, and the choice of reconstruction modality for postoperative gastrointestinal tract. The advent of the minimally invasive era has brought the treatment of Siewert type II AEG to a stage of gradual improvement and standardization. Experts of China are also actively exploring the value of minimally invasive surgery in the treatment of AEG through multicenter trials (CLASS-10, etc.). It is believed that based on the active development of many clinical studies, basic experimental studies and large prospective clinical studies, the strengthening of communication and cooperation among various disciplines and the innovative application of new technologies can bring greater survival benefits to patients.
Adenocarcinoma/pathology* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Gastrectomy ; Humans ; Lymph Node Excision ; Minimally Invasive Surgical Procedures ; Prospective Studies ; Retrospective Studies ; Stomach Neoplasms/pathology*

A greater controversy remains in clinical diagnosis and treatment of Siewert type II adenocarcinoma of esophagogastric junction (AEG), compared with Siewert type I and III AEG. In 2018, the first edition of Chinese Expert Consensus on the Surgical Treatment for Adenocarcinoma of Esophagogastric Junction was published in the Chinese Journal of Gastrointestinal Surgery. In the past few years, the advance in minimally invasive thoracoscopic surgery has been proven to reduce thoracic trauma in Siewert type II AEG. Meanwhile, distal thoracic esophagectomy can achieve more complete resection, and upper abdomen-right thoracic approach can ensure the mediastinal lymph node dissection and improve long-term survival. The concept and practice of endoscopic surgery and the comprehensive treatment also give new supplements to the treatment regimen of Siewert type II AEG. More clinical researches should be conducted to address the surgical residual safety and lymph node dissection issues.
Adenocarcinoma/pathology* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Gastrectomy ; Humans ; Lymph Node Excision ; Retrospective Studies ; Stomach Neoplasms/surgery* ; Thoracic Surgery

The proportion of adenocarcinoma of the esophagogastric junction (AEG) in gastric cancer is gradually increasing. Due to the unique anatomical structure and biological characteristics of the tumor at this site, AEG has a certain degree of complexity in many aspects of diagnosis and treatment, which brings difficulties to the operation method, the selection of the resection range, the lymph node dissection and the treatment decision-making. Therefore, AEG has always been the focus of academic debate. With the development of minimally invasive surgery in recent years, laparoscopic technology has been increasingly mature and widely used in the treatment of gastrointestinal tumors. Compared with distal gastric cancer, the minimally invasive treatment of AEG is in a lagging state, and there are also a series of problems that have not yet reached a consensus. This article reviews and summarizes the recent research progress in two aspects: proximal gastrectomy for AEG and lymph node dissection. Laparoscopic-assisted proximal gastrectomy is safe for early proximal gastric cancer and has a long-term survival outcome not inferior to total gastrectomy, but the surgical indications must be strictly selected. Abdominal lymph node metastasis of AEG is mainly in group 1, 2, 3, and 7, and mediastinal lymph node metastasis is closely related to the length of the infiltrated esophagus. The abdominal transhiatal (TH) approach can obtain a sufficient number of harvested lymph node, and has good safety and efficacy, which is the first-choice of surgical approach for early AEG. The results of the CLASS-10 clinical trial can provide a higher level of evidence for laparoscopic mediastinal lymph node dissection. Laparoscopic surgery for AEG should be carried out in experienced medical center based on clinical research.
Adenocarcinoma/surgery* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Gastrectomy/methods* ; Humans ; Laparoscopy/methods* ; Lymph Node Excision/methods* ; Lymph Nodes/surgery* ; Retrospective Studies ; Stomach Neoplasms/surgery*

The lower mediastinal lymphadenectomy is indicated for adenocarcinoma of esophagogastric junction (AEG), while the laparoscopic procedure shows some advantages. According to previous studies and results of IDEAL phase 2a study in our institute, the following structures are recommended as the dissection borders: the upper (cranial) is inferior wall of pericardium and pulmonary ligament; the lower (caudal) is diaphragm hiatus (esophagogastric junction); the front (ventral) is anterior inferior wall of pericardium and diaphragm; the back (dorsal) is anterior wall of aorta; the lateral is mediastinal pleura. The standard of quality control is still under investigation.
Adenocarcinoma/surgery* ; Esophageal Neoplasms/surgery* ; Esophagogastric Junction/surgery* ; Humans ; Laparoscopy/methods* ; Lymph Node Excision/methods* ; Quality Control ; Retrospective Studies ; Stomach Neoplasms/surgery*