Evidence-based approach to the treatment of esophagogastric junction tumors

The incidence of esophagogastric junction(EGJ)adenocarcinoma is increasing in developed nations due to the rising prevalence of obesity and gastroesophageal reflux disease.Due to the peculiar location in a histological transition zone between the esophagus and the stomach,the management of EGJ tumors is controversial.Two main surgical approaches exist:total gastrectomy with distal esophagectomy or esophagectomy by either transhiatal or transthoracic approach.These operations differ significantly in the extent of lymphadenectomy.In addition,patients with locally advanced disease can receive either preoperative chemoradiation or perioperative chemotherapy.This evidence-based review analyzes current evidence regarding the management of EGJ tumors in order to help defining the best surgical and systemic treatment of these patients.

Surgical resection of esophagogastric junction stromal tumor: How to protect the cardiac function

BACKGROUND Various surgical procedures have been described for gastrointestinal stromal tumors(GISTs)at the esophagogastric junction(EGJ)close to the Z-line.However,surgery for EGJ-GIST involving Z-line has been rarely reported.AIM To introduce a novel technique called conformal resection(CR)for open resection of EGJ-GIST involving Z-line.METHODS In this retrospective study,43 patients having GISTs involving Z-line were included.The perioperative outcomes of patients receiving CR(n=18)was compared with that of proximal gastrectomy(PG)(n=25).RESULTS CR was successfully performed in all the patients with negative microscopic margins.The mean operative time,time to first passage of flatus,and postoperative hospital stay was significantly shorter in the CR group(P<0.05),while the intraoperative blood loss was similar in the two groups.The postoperative gastroesophageal reflux as diagnosed by esophageal 24-h pH monitoring and quality of life at 3 mo were significantly in favor of CR compared to PG(both P<0.001).The 5-year disease-free survival between the two groups was similar(P=0.163).The cut-off value for the determination of CR or PG was 7.0 mm above the Z-line(83.33%sensitivity,84.00%specificity,83.72%accuracy).CONCLUSION CR is safe and feasible for EGJ-GIST located within 7.0 mm above the Z-line.

Esophagogastric junction adenocarcinoma:Preoperative chemoradiation or perioperative chemotherapy?

Multimodal treatment is currently the standard of care for locally advanced esophagogastric junction(EGJ)adenocarcinoma due to poor results after surgery alone.Neoadjuvant therapy is intended to shrink the tumor and eliminate potential circulating tumor cells.However,which neoadjuvant treatment is best for patients with EGJ tumors remains controversial.We aimed to compare outcomes of preoperative chemoradiation and perioperative chemotherapy for EGJ adenocarcinomas.For this purpose,we performed a thorough review of the literature describing neoadjuvant treatments for EGJ adenocarcinomas or comparing both therapies.Although some studies have shown better locoregional control and higher rates of complete pathologic response after chemoradiation,data suggest that both types of neoadjuvant therapy have similar survival benefits.As current data are heterogeneous and many studies have included significantly different types of patients in their analysis,future studies with better patient selection are still needed to define which neoadjuvant therapy should be chosen.In addition,targeted therapies and immunotherapy have promising results and should be further explored.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND Reflux esophagitis is a common postoperative complication of proximal gastrectomy.There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy.We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis(EGAA)can prevent postoperative reflux in a safe and feasible manner.To observe a novel method of EGAA to prevent postoperative reflux.METHODS Initially,we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis.This was done in order to better understand the anti-reflux function and mechanism.Next,we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy.Post-surgery,we monitored the structure and function of the reconstruction through imaging exams and gastroscopy.Finally,the patients were followed up to assess the efficacy of the anti-reflux effects.RESULTS Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma,providing a means to prevent the reverse flow of gastric fluids.Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy,with a mean operation time of 304.2±44.3 min.After the operation,the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux,three had mild reflux,and two had obvious reflux.The abdominal computed tomography examination showed a valve-like structure at the anastomosis.During followup,gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients.Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.CONCLUSION EGAA is a feasible and safe surgical method,with an excellent anti-reflux effect after proximal gastrectomy.