Society for Surgery of the Alimentary Tract
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Durval R. Wohnrath4, Raphael O. Silva5,1, Raphael L. Araujo*1,2,3
1Department of Surgery, Universidade Federal de Sao Paulo, Universidade Federal de Sao Paulo, Sao Paulo, São Paulo, BR, academic/system, Sao Paulo, SP, Brazil; 2Hospital e Maternidade Brasil, Santo Andre, São Paulo, Brazil; 3Sociedade Beneficente Israelita Brasileira Albert Einstein, Sao Paulo, São Paulo, Brazil; 4Hospital de Amor, Barretos, São Paulo, Brazil; 5Hospital Ministro Costa Cavalcanti, Foz do Iguacu, Paraná, Brazil

Background: The surgical approach for Esophagogastric Junction Cancers (EJC), Siewert II, has been controversial in terms of margin control, reconstruction, and lymphadenectomy extension. Furthermore, both AJCC and UICC also recognize the biological heterogeneity of EJC coexisting in the same TNM. In the case of Siewert II tumors, predicting the need for either total esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be difficult, with each direction usually excluding the other. The pre-operative image workout may not accurately determine the need for each procedure. Complication rates for DETG have historically been higher, affecting systemic treatment and long-term outcomes. In this series, we describe the standardization and outcomes of an intra-operative decision-making strategy that allows both surgical approaches until frozen section guidance, rather than just following preoperative image planning, and offers the oncologic procedure with lower complication rates (TGDE) as much as possible.
Aim: The goal of this study is to describe a surgical strategy for approaching Siewert II EJC, with the intraoperative decision to perform total gastrectomy with lymphadenectomy D2 or esophagectomy with mediastinal and retroperitoneal lymphadenectomy based on intraoperative frozen section.
Methods: All patients underwent surgery, beginning with greater curvature detachment while preserving the right gastroepiploic, right, and left arteries; dissection of the esophageal hiatus for both node harvesting and transection of the distal esophagus and its frozen section. If the margin was free, DETG was preferred; if the margin was positive, TEPG and gastric tube reconstruction were performed, as shown in the figure.
Results: thirty-eight patients with EJC Siewert II with adenocarcinoma who underwent this standardization, 26 (68%) were submitted to TGDE and 12 (32%) for TEPG, and the clinic-pathological data and surgical outcomes are shown in the table. Briefly, the TEPG showed a trend toward higher complication rates, higher positive margins, and shorter overall survival, but it was not statistically significant.
Conclusion: Surgery for EJC requires a careful evaluation of their disease extension, to perform an adequate procedure for each case. Although this study found no significant differences in morbidity between the two procedures, type II errors must be considered a possible cause. This surgical strategy favors a stepwise approach to the cardia tumor, with stomach sparing and vascularization for an occasional gastric tube until free margins in the frozen section can be safely confirmed. Thus, in some cases with Siewert II tumors, unnecessary esophagectomies can be avoided without jeopardizing either surgical or oncologic outcomes, and opting for a procedure with less morbidity, according to the literature.

Figure: Intraoperative image sequence of the stepwise approach for Siewert II tumors; A - exposure of distal esophagus with tumor (dashed ellipsis); B – the esophagus margin preparation for frozen section; C – stomach with preserved right gastroepiploic (red arrows), right and left gastric arterial arcades whereas the frozen section is made; D – cervical esophagus-gastric anastomosis in case of positive margin in the distal esophageal frozen section, and using a gastric tube nourished through right gastroepiploic and right gastric arterial arcades (E).

Table: Clinicopathological distribution and surgical outcomes according to the type of procedure necessary to treat esophagogastric junction cancers (Siewert II)

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