Background: The classification and the surgical management of patients with true cardia carcinoma of the esophago-gastric junction (AEG Type II according to Siewert’s classification) are still controversial. In the classification of these tumour entity the UICC guidelines for gastric or esophagus carcinoma is contrary used and a standard surgical approach is missing. A clear outline for the surgical technique is requested.
Methods: We investigated 532 consecutive resected patients with an AEG Type II, the classification according the UICC guidelines for gastric and esophageal carcinoma were used and the optimal surgical approach was reported.The tumour infiltration, lymph node and distant metastases, residual tumour and the long time outcome were evaluated. Statistical analysis with Kaplan-Meier-Survival and Cox regression analysis were performed.
Results: Of the 532 consecutive resected patients, in 379 (71.2%) a transhiatal extended gastrectomy, in 91 (17.1%) an esophagectomy, in 32 (6.0%) an esophago-gastrectomy, and in 30 (5.7%) a limited resection of the cardia were performed. The strictly indication for an esophagectomy or esophago-gastrectomy in up to 23% of the patients were the preoperatively (endoscopy) or intraoperatively (biopsy) detected tumour infiltration of the distal esophagus or lymph node metastases in the mediastinum. The R0-resection rate was with all approaches greater than 74%. In early carcinoma, limited to the mucosa or submucosa, the limited resection of the cardia with oncological lymphadenectomy and reconstruction with pedicled jejunal graft showed optimal results in the long-time follow-up (R0-resection rate 100%, 5-year survival 96%).The operative complications, the radicalism of the procedures and the long time survival between gastrectomy and esophagectomy are not significant different (p>0.05). For the evaluation of the prognostic outcome showed the UICC classification for gastric carcinoma in true cardia carcinoma the better differentiation.
Conclusion: The classification and operative approach in true carcinoma of the cardia request an own regulation. With the infiltration of the distal esophagus an esophagectomy is oncologically required and results not in elevated complications or reduction of the long time prognosis.