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Primary Therapy: Surgical Method—GEJ Cancer
Although adenocarcinomas arising at or near the GEJ are often classified as esophageal carcinoma, there has been a concerted effort to differentiate treatment approach based on location and cell origin.87-93 Feith, Siewert, and colleagues defined adenocarcinomas of the GEJ into three separate types87,94:
Type I: Adenocarcinoma of the distal esophagus, arising as intestinal metaplasia of the esophagus and possibly infiltrating the GEJ from above
Type II: Adenocarcinoma of the cardia, arising from cardiac epithelium or short segments with intestinal metaplasia at the GEJ
Type III: Subcardial gastric carcinoma, infiltrating the GEJ and distal esophagus from below.
Surgical resection has remained controversial as to the necessary extent of proximal esophageal resection, distal gastric resection, and lymph node dissection.95-101 Complete macroscopic and microscopic resection (R0) provides patients with the best survival.89,94,97,98,100-103 The main goal of lymph node dissection is to optimize staging and reduce locoregional relapse, and lymph node involvement is recognized as a major prognostic factor in GEJ adenocarcinoma.96,99,103,104 Decisions as to the type of surgical resection should be based on achieving an R0 resection and can include transhiatal, transthoracic, partial, and total gastrectomy.
For Type I GEJ cancers, surgical resection should include esophagectomy with at least 6 to 8 cm of proximal margin.89,96,98,100,105 Either transhiatal or transthoracic esophagectomy can be used to achieve an R0 resection.
Both transhiatal and transthoracic esophagectomy include an identical abdominal procedure to assess metastases, mobilize the stomach, and create a gastric tube that will replace the resected esophagus and proximal stomach. Lymph node dissection is also performed along the celiac axis and peripancreatic region. The abdominal portion of the operation can be done either open or with laparoscopy depending on surgeon experience and preference (E-Fig. 75-3A).
Transthoracic cases will then be completed through a right side of the chest approach. Either open posterolateral thoracotomy or minimally invasive thoracoscopy can be used (E-Fig. 75-3B). The transthoracic approach allows extensive mediastinal lymphadenectomy to be performed as well as resection of periesophageal fat and adhesions. The gastric tube is brought up into the chest through the diaphragm and anastomosed to the proximal esophagus in the upper thorax. Multiple anastomotic techniques have been described.106 For minimally invasive esophagectomy (MIE), we have successfully used an OrVil EEA (U.S. Surgical Corps.) which allows a 25-mm anvil to be advanced through the mouth while attached to an orogastric tube (E-Fig. 75-3C).105,107 The anvil is then pulled through a small opening made in the proximal esophagus (E-Fig. 75-3D) and attached to the pin of the stapler that has been advanced through the back wall of the gastric conduit (E-Fig. 75-3E). There have been no large randomized trials on MIE versus open options for GEJ adenocarcinoma; therefore, evidence-based recommendations cannot be made. There is some suggestion of fewer pulmonary complications and faster recovery with MIE.107-110
Transhiatal procedures are completed through a cervical incision on the left neck. The esophagus is freed through this incision and hand dissection from below the diaphragm allows the specimen to be brought up through the neck incision (E-Fig. 75-3F). The conduit is anastomosed to the proximal esophagus in the neck. This can be performed with hand sewing or stapling devices (E-Fig. 75-3G). Generally a formal mediastinal lymphadenectomy is not performed with this technique.
Surgical resection for Type II GEJ cancers can be performed with a proximal gastrectomy and partial esophagectomy. The transthoracic approach is preferred providing a two-field extended lymphadenectomy and tension-free anastomoses given the additional gastric margin needed.
Type III GEJ cancers require extensive gastric resection to provide an inferior margin of 2 to 3 cm and a superior margin of 4 to 5 cm.95,111 A total gastrectomy with partial esophagectomy and Rouxen-Y bile diversion through an abdominal approach is generally necessary to achieve R0 resection.95,111,112 These cancers are treated similar to pure gastric cancers. The strategy for GEJ cancers is most often multidisciplinary, but surgery remains a critical part of the treatment plan for resectable carcinomas. Surgical techniques continue to evolve in an attempt to minimize patient morbidity and mortality.