Survival Benefit of Pyloric Lymph Node Dissection for Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction Based on Tumor Diameter: A Large Cohort Study

BackgroundIt is unclear whether the dissection of pyloric lymph nodes (PLNs, No. 5 and No. 6 lymph nodes) is necessary for adenocarcinoma of the esophagogastric junction (AEG) with a tumor diameter >4 cm based on current guidelines. This study aimed at evaluating whether pyloric node lymphadenectomy is essential for patients with Siewert type II/III AEG according to different tumor diameters.MethodsThis study included 300 patients on whom transabdominal total gastrectomy was performed for Siewert type II/III AEG at a high-volume center in China from January 2006 to December 2015. The index of estimated benefit from lymph node dissection (IEBLD) was used to analyze the priority of pyloric lymphadenectomy.ResultsIn Siewert type II AEG, the 5-year overall survival (OS) and the 5-year disease-free survival (DFS) were similar between patients with PLN-positive cancer and patients of stage III AEG without PLN metastasis (23.1% vs. 30.6%, p = 0.505; 23.1% vs. 27.1%, p = 0.678). However, in Siewert type III AEG, the OS and the DFS of patients with PLN-positive cancer were significantly lower than that of patients with stage III without PLN metastasis (7.9% vs. 27.8%, p = 0.021; 0 vs. 26.8%, p = 0.005). According to the IEBLD, the dissection of PLNs did not appear to be beneficial in either Siewert type II AEG or type III AEG, whereas a stratified analysis revealed that PLN dissection yielded a high therapeutic benefit for Siewert type II AEG with tumor diameters >4 cm.ConclusionWe recommended that the PLNs be dissected in Siewert type II AEG when a tumor diameter is >4 cm. Total gastrectomy should be optional for Siewert type II AEG with a tumor diameter >4 cm and Siewert type III AEG.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Long-term survival in 101 metastatic gastroesophageal cancer (mGEAC) patients eventually treated with consolidative local therapy.

197 Background: Through a multidisciplinary decision-making process, we developed a strategy of systemic therapy followed by local consolidative therapy (chemoradiation and/or surgery) for selected mGEAC patients. We present results in a large cohort. Methods: From our database, we identified a 101 such patients. We analyzed the association of various clinical variables (location of primary, location of metastases, duration of initial chemotherapy, histologic grade, and radiation dose {≥50.4 Gy vs. <50.4 Gy}) with overall survival (OS). Results: There were 71 patients with proximal primary (esophageal, Siewert types I/II) and 30 patients with distal primary (Siewert type III and gastric). The median OS was 25.7 months (95% CI: 22.3-32.8 months). The OS rates at 2-years and 5-years from diagnosis were 53.8% (95% CI: 44.7%-64.8%) and 20.7% (95% CI: 13.4%-31.9%), respectively. The median OS was highly associated with the location of primary (22.8 months for proximal GEACs vs. 41.5 months for distal GEACs, p=0.03). Duration of initial chemotherapy was highly associated with OS (21.8 months for <3 months vs. 32.5 months for ≥3 months, p=0.004). Association between OS and tumor/treatment characteristics. Conclusions: Selected patients with mGEAC (who have favorable clinical course) can have up to 20% 5-year survival with this strategy. Patients with distal GEAC and those who receive initial chemotherapy for longer time are the maximum beneficiaries. [Table: see text]