Exploration and optimization of surgical techniques for laparoscopic transhiatal lower mediastinal lymph node dissection for adenocarcinoma of esophagogastric junction: A prospective IDEAL 2a study with qualitative design

Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.

Adenocarcinoma of esophagogastric junction:controversial classification,surgical management,and clinicopathology

In recent years the world is witnessing an increasing incidence of adenocarcinoma of esophagogastric junction （AEG）, which originates from epithelial tissue of esophagogastric junction （EGJ）, and mainly derives from Barrett＇s esophagus. It＇s now gaining more and more attention due to the controversial etiology, classification and treatment.

Adenocarcinoma of esophagogastric junction

To date,there has been a dramatic increase in the incidence of adenocarcinomas of the esophagogastric junction （AEG）worldwide.The classification of AEG,defined by Siewert and Stein,was approved at the second International Gastric Cancer Congress in Munich in April 1997.In accordance with the anatomic cardia,EGJC can be divided into three subtypes：type Ⅰ,adenocarcinoma of the distal esophagus with the center located within 1 cm above and 5 cm above the anatomic esophagogastric junction （EGJ）;type Ⅱ,true carcinoma of the cardia with the tumor center within 1 cm above and 2 cm below the EGJ;type Ⅲ,subcardial carcinoma with the tumor center between 2 and 5 cm below EGJ,which infiltrates the EGJ and distal esophagus from below （1）.

A case of Photodynamic Therapy for Advanced Adenocarcinoma of Esophagogastric Junction

Photodynamic therapy(PDT)is a new minimally invasive technique for the treatment of tumors.Compared with traditional treatments such as surgery,radiotherapy and chemotherapy,PDT has the advantages of targeted killing of primary and recurrent tumor cells,less damage to surrounding normal tissue,less complications and high repetition rate.The purpose of this study was to investigate the short-term efficacy and adverse reactions of photodynamic therapy in advanced elderly patients with esophageal-gastric junction adenocarcinoma without surgical indications.A patient with advanced adenocarcinoma of esophagus and fundus was treated with photodynamic therapy under gastroscope.Intravenous drip of Cipofen(hematoporphyrin injection 150mg/0.9%saline 250ml)for 1 hour to keep the patient away from light.48 hours after administration,photodynamic therapy was performed with"Leimai"PDT630-A photodynamic therapy apparatus,3cm columnar optical fiber,laser treatment wavelength of 630nm,transmission efficiency of 0.70,output power of 1.4W,irradiation at the lower segment of the esophagus and cardia for 150s.The curative effect was evaluated by comparing gastroscopy before and after photodynamic therapy.Before treatment,there were proliferative lesions in the lower part of esophagus and cardia,erosion and necrosis on the surface,stricture of esophageal cavity,huge ulcer near gastric fundus,filthy moss and dam-like hyperplasia and eminence of surrounding mucosa.After treatment,the local mucosa at the entrance of cardia became white and there was no bleeding.Within four days after treatment,the symptoms of nausea and vomiting disappeared;the adverse reaction of retrosternal discomfort began to occur on the second day after operation,and the adverse reaction was not improved after photodynamic therapy.Photodynamic therapy has a significant short-term effect on advanced elderly patients with adenocarcinoma of the esophagogastric junction,which can significantly alleviate the clinical symptoms and relieve the pain of the patients.However,the adverse reactions can not be ignored.Therefore,photodynamic targeting therapy for tumor needs to be futher studied.It is believed that with the continuous development of high-performance photosensitizers and new generation lasers,and the continuous progress of endoscopy and image guidance technology,photodynamic therapy will become an important adjuvant or palliative treatment for tumor prevention and treatment.

Comparison of survival outcomes between transthoracic and transabdominal surgical approaches in patients with Siewert-Ⅱ/Ⅲesophagogastric junction adenocarcinoma:a single-institution retrospective cohort study

Objective： To compare the survival outcomes of transabdominal （TA） and transthoracic （TT） surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma. Methods： This retrospective study was conducted in patients with Siewert-II/III esophagogastric junction adenocarcinoma who underwent either TT or TA operations in the West China Hospital between January 2006 and December 2009. Results： A total of 308 patients （109 in the TT and 199 in the TA groups） were included in this study with a follow-up rate of 87.3%. The median （P25, P75） number of harvested perigastric lymph nodes was 8 （5, 10） in the TT group and 23 （16, 34） in the TA group （P〈0.001）, and the number of positive perigastric lymph nodes was 2 （0, 5） in the TT group and 3 （1, 8） in the TA group （P〈0.004）. The 5-year overall survival （OS） rate was 36% in the TT group and 51% in the TA group （P=0.005）. Subgroup analysis by Siewert classification showed that 5-year OS rates for patients with Siewert II tumors were 38% and 48% in TT and TA groups, respectively （P=0.134）, whereas the 5-year OS rate for patients with Siewert III tumors was significantly lower in the TT group than that in the TA group （33% vs. 53%; P=0.010）. Multivariate analysis indicated that N2 and N3 stages, RI/R2 resection and a TT surgical approach were prognostic factors for poor OS. Conclusions： Improved perigastric lymph node dissection may be the main reason for better survival outcomes observed with a TA gastrectomy approach than with TT gastrectomy for Siewert III tumor patients.

Recent advances in multidisciplinary therapy for adenocarcinoma of the esophagus and esophagogastric junction

Esophageal adenocarcinoma(EAC)and adenocarcinoma of the esophagogastric junction(EGJA)have long been associated with poor prognosis.With changes in the spectrum of the disease caused by economic development and demographic changes,the incidence of EAC and EGJA continues to increase,making them worthy of more attention from clinicians.For a long time,surgery has been the mainstay treatment for EAC and EGJA.With advanced techniques,endoscopic therapy,radiotherapy,chemotherapy,and other treatment methods have been developed,providing additional treatment options for patients with EAC and EGJA.In recent decades,the emergence of multidisciplinary therapy(MDT)has enabled the comprehensive treatment of tumors and made the treatment more flexible and diversified,which is conducive to achieving standardized and individualized treatment of EAC and EGJA to obtain a better prognosis.This review discusses recent advances in EAC and EGJA treatment in the surgicalcentered MDT mode in recent years.

Risk factors associated with early recurrence of adenocarcinoma of gastroesophageal junction after curative resection

Objective： To clarify the important clinicopathological factors affecting the early recurrence of adenocarcinoma of esophagogastric junction （/kEG）. Methods： We retrospectively reviewed the clinical data of 147 AEG patients who underwent R0 resection during the period from December 1995 to December 2007. Risk factors asssociated with the early recurrence were analyzed by X2 test and logistic regression test. Results： The mean time to tumor recurrence was 16.3 months after R0 resection, and the 1-year recurrence rate was 48.3%. Univariate analysis showed that the histological grade （poorly and moderately differentiated）, number of positive lymph nodes, and vascular invasion were significantly related with the early recurrence （P〈0.05）. Logistic multivariate regression analysis showed that only histological grade and vascular invasion were independently related with early tumor recurrence （P〈0.05）, Conclusions： Histological grade and vascular tumor recurrence after R0 resection for/kEG. invasion are independent factors for predicting the early