General and Esophageal Surgery Clinic

“St. Mary” Clinical Hospital,

Bucharest, ROMANIA

Surgical approach in
esophagogastric junction
adenocarcinoma
Rodica Birla
University of Medicine and Pharmacy “Carol Davila”, Bucharest
General and Esophageal Surgery Clinic
“St. Mary” Clinical Hospital,
ADENOCARCINOMUL (AC) DE
JONCŢIUNE ESO-GASTRICĂ
(JEG) WORLD HEALTH ORGANIZATION
INTERNATIONAL AGENCY FOR RESEARCH ON CANCER
 AC ce străbat JEG sunt denumite AC de JEG fără a ţine
seama de locul cu volum tumoral mai mare
 AC localitate în întregime deasupra JEG sunt considerate
adenocarcinoame esofagiene
 AC localizate în întregime sub JEG sunt considerate AC
gastrice proximale sau corporeale în funcţie de mărimea
lor

 Carcinomul scuamocelular (CS) ce apare la nivelul JEG

este considerat carcinom al esofagului distal chiar dacă
străbate JEG

WORLD HEALTH ORGANIZATION CLASSIFICATION OF TUMOURS

(2000)
 CLASIFICAREA SIEWERT

• SIEWERT aplică termenul carcinom de

cardie AC ale JEG definită ca o regiune de
5cm deasupra şi dedesubtul liniei Z

• dacă joncţiunea mucoasă e deplasată proximal ca

în esofagul Barrett se ia ca reper cardia
anatomică
• carcinoamele subcardiale sunt incluse numai
dacă infiltrează esofagul distal
• unii adaugau drept criteriu secundar necesitatea
unui abord abdomino-toracic sau abdomino-
transhiatal
 International Gastric Cancer Association (IGCA)
International Society for Diseases of the Esophagus
(ISDE)
Siewert & Stein – 1998

Tipul I- adenocarcinom al esofagului

distal plecând dintr-o zonă de
metaplazie intestinală (esofag Barrett)
- 1-5 cm deasupra cardiei
anatomice
Tipul II- carcinom al cardiei plecând de
la epiteliul cardial sau segmentul scurt
de metaplazie intestinală al joncţiunii
E-G (carcinom joncţional)
-1 cm deasupra şi 2 cm sub
cardia anatomică
Tipul III- carcinom gastric subcardial
 Diseases
Classification of the esophagogastric
junction adenocarcinoma

I. EC (eso-cardial): the bigest part of

the tumor is located above cardia
II. E = C (cardial): the tumoral mass is
equal divided on abdominal
esophagus and stomach
III. CE (cardio-esophageal): the bigest
part of the tumor is located on the
fornix
 Preoperative
strategy
• Esophageal tumor diagnosis and TNM
classification:
– Clinical presentation
– EGD + biopsy
– EUS + FNA
– Barium passage
– CT of thorax and abdomen
– Diagnostic laparoscopy
 TNM
• Siewet I – esophageal TNM classification
• Siewert II,III – gastric TNM classification

• UICC sugerează încadrarea adenocarcinomului de

joncţiune esogastrică drept cancer esofagian dacă mai
mult de 50% din masa tumorală este situată la nivelul
esofagului şi cancer gastric dacă mai mult de 50% din
tumoră este localizată la nivelul stomacului.
 TNM stage I
– T is – endoscopic ablative method
– T with submucosa invasion –
gastro-esophageal limited
resection (ex: Merendino
procedure)
 TNM stage II
• Establishing Siewert type
• The resection goal (EUS +
FNA):
– Curative resection
 TNM stage III –
locally advanced
tumors
– Establishing Siewert type
– Establishing resectability
– Neoadjuvant RCT
– The resection goal: HER2 3+
• Curative resection
• Palliative resection
 Preoperative strategy

• TNM stage IV
– Palliative treatment
• Radio and chemotherapy
• Esophageal stent
• Esophageal by-pass
• Gastro/jejuno-stomy
 Surgical approach
(according to Siewert type
• Type I (EC):
and JSDE)
– Triple approach
– Abdomino-cervical approach
• Type II (E=C):
– Thoraco-phreno-laparotomy
– Abdomino-cervical approach
– Abdomino-transhiatal approach
• Type III (CE):
– Thoraco-phreno-laparotomy
– Abdomino-transhiatal approach
 Preoperative strategy

• Contraindications for thoracic approach

– Clinical:
• Age (>75 years)
• Associated pulmonary pathology
– Investigations:
• Respiratory function tests (FEV1 < 1,25l)
• Cardio Doppler (resting ejection fraction of less
than 40%)
 Intraoperative strategy

• Resection and lymphadenectomy

(according to Siewert or JSDE type)
• Reconstruction
• Temporary feeding path
 Exploration
Intraoperative
histopathologic
examination

Resectability and The level of

± Splenectomy
resection extent lymphadenectomy
Resection extent and
limphadenectomy
Abdomino-toracic approach :
subtotal esofagectomy with
small gastric curvature
resection and mediastinal
eso-gastrostomy
 Abdomino-cervical approach :
subtotal esofagectomy with small
gastric curvature resection and
cervical eso-gastrostomy
 Abdomino-cervical approach : total
gastrectomy with subtotal
esophagectomy and colic interposition
 Thoraco-phreno-laparotomy
approach: total gastrectomy with
distal esophagectomy and eso-
jejunostomy
 Abdomino-transhiatal
approach : total
gastrectomy with distal
esophagectomy and eso-
jejunostomy
 Mediastinal end to side
eso-jejunostomy with a
 jejunal loop

• Cervical eso-gastrostomy Cervical eso-colostomy

Anastomotic leak
 Postoperative mortality

Complication type No.

Cases
MSOF 4
Stroke 3
Bronchopneumonia 3
Acute myocardial infarction 1
TOTAL 11(10%)
 Comments
Postoperative mortality could be reduced
by:
• Improved patient selection:
– Better preoperative staging.
– Clinical and biological evaluation of the
patients regarding age, cardio-pulmonary
function and intraoperative staging
• Improved operating technique and
approach due to increased experience
 Upper
endoscopy
control
 Conclusions
• Beside clinical and paraclinical examination, preoperative
Siewert type establishing is necessary to select surgical
strategy.

• Esophagogastric junction approach through thoraco-

phreno-laparotomy allows to perform an esophagogastric
resection with oncological lymph node dissection , but is
involved in increasing postoperative mortality .

• Total gastrectomy with distal esophagectomy through

abdominal approach can be an optimal surgical method
in elderly patients with respiratory deficiences.
• Intra-operative pathologic examination of
esophageal resection margins should be routinely
done, especially in esophago-gastric resections
through abdomino-transhiatal approach.

• Periodic endoscopic surveillance during the first

postoperative year (once every three months) is
recommended for tumoral recurrences diagnosis
and also for the evaluation of the anastomosis
complex