Adenocarcinoma of the Esophagogastric Junction by Paul M. M. Schneider

Author:Paul M. M. Schneider
Language: eng
Format: epub
Publisher: Springer Berlin Heidelberg, Berlin, Heidelberg

8.2 Surgical Strategies for AEG Siewert Type I

AEG Type I carcinomas (in the vast majority Barrett’s cancer) are esophageal cancers. The surgical strategy for these tumors is based on the lymph node metastases pattern and the localization of the tumor in the distal esophagus. For AEG type I tumors, a subtotal resection of the esophagus is frequently mandatory (Fig. 8.1). In general, there are two major resection strategies, which are recommended for the type I tumors: the transthoracic en bloc resection and the transhiatal resection, first described by Grey Turner in 1933. There is limited evidence available to demonstrate a clear advantage of one of the two procedures. However, a randomized clinical trial (RCT), which compared the two techniques, showed a 10% survival benefit (29% vs. 39%) for the transthoracic group (Hulscher et al. 2002; Omloo et al. 2007). This finding was confirmed in the 5-year follow-up data, with a reported survival benefit of 14% for type I tumors (51% vs. 37%) in the transthoracic group (Omloo et al. 2007). The significant effect was dependent on the number of positive lymph nodes in the ­resection specimen. If less than eight positive lymph nodes were present, the disease-free survival benefit was significantly higher in the transthoracic group (23% vs. 64%, p = 0.02). More than eight positive lymph nodes were associated with a poorer outcome, indicating the presence of a systemic disease as a possible explanation. One shortcoming of this study was the higher proportion of stage IV patients in the transthoracic group (15% vs. 7%), which might be responsible for the relatively modest statistical benefit of the transthoracic technique in the whole study population. Overall, the results highlight the importance of an accurate lymph node staging and resection, which is only possible with a transthoracic en bloc resection of the esophagus. The significantly increased pulmonary morbidity, which has been observed in the transthoracic approach (57% transthoracic vs. 27% transhiatal, p < 0.001), did not result in a higher perioperative mortality (4% transthoracic vs. 2% transhiatal, n.s.) and can be minimized in experienced centers, as convincingly demonstrated in this trial.

The extent of the LAD for adenocarcinomas and squamous cell carcinomas of the esophagus has been controversially discussed for many years. To describe the extent of the LAD, we use the classification published by Fujita et al. in 2003, which represents the classification of the ISDE consensus conference from 1994. In brief, standard LAD involves the lower mediastinal and upper abdominal nodes, which can be achieved by a transhiatal resection. Extended LAD (two-field LAD) includes the resection of the subcarinal, right paratracheal/upper mediastinal nodes, and left tracheobronchial nodes to the upper border of the aortic arch (entrance of the left recurrent laryngeal nerve), in addition to the standard procedure. The total LAD or extended two-field LAD involves the resection of the bilateral recurrent laryngeal nerve nodes. A three-field LAD includes the resection of the cervical ± supraclavicular nodes. The various extents of LAD for esophageal cancer including AEG type I are shown in Fig.

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