36
pretreatment classification may not always be accurate; because of
tumor overgrowth, the presence of Barrett’s epithelium and hiatus
hernia, accurate location of the esophagogastric junction is diffi-
cult, affecting the classification. Despite its drawbacks, it serves as
the backbone for many studies over the years and does enhance
communications among physicians.For resection of adenocarcinoma around the esophagogastric junc-
tion, one aims at removing the primary tumor with negative proxi-
mal, distal, and lateral margins, together with adequate
lymphadenectomy of the potential basins of lymph node spread.
For esophageal adenocarcinoma (Siewert type I), in general an
esophago-gastrectomy with resection of the intrathoracic esopha-
gus together with the proximal stomach is performed. The distal
stomach is used to reconstitute intestinal continuity. Commonly, it
is brought up into the right thoracic cavity for an intrathoracic
esophago-gastrostomy (this is referred to as an Ivor-Lewis or
Lewis-Tanner esophagectomy). Some surgeons prefer bringing the
gastroplasty up to the neck for cervical anastomosis [ 2 ]. For this
however, a longer stomach tube is required and adequate distal
margin from the primary cancer must be a prerequisite for this
method.
For Siewert type III cancers, most surgeons regard them as a
proximal gastric cancer with infiltration upwards to the gastresoph-
ageal junction, and as such usually a total radical gastrectomy is
performed via the abdominal approach, provided a negative proxi-
mal margin can be obtained histologically.
Siewert type II cancers are most controversial. In western
countries, they are treated more like type I cancers and thus many
would perform similar Ivor Lewis operation. In Asian countries,
these cancers are more addressed as gastric cancer and therefore an
abdominal approach for a total gastrectomy is often performed
[ 3 ]. Some surgeons advocate a left thoraco-abdominal approach.
Lymphadenectomy also varies according to Siewert type (or
the proximal and distal extent of the primary tumor). Again in
general, for type I cancers, they are treated as esophageal cancers
and therefore a standard two-field dissection (upper abdominal
lymphadenectomy around the celiac axis and mediastinal lymphad-
enectomy below the tracheal bifurcation) is employed. Supra-
carinal lymph nodes are rarely removed because it is believed that
nodal spread above the bifurcation is uncommon, and if present,
indicates poor prognosis that would negate the benefits of extended
nodal dissection in this area. For type III cancers, a D2 lymphad-
enectomy is performed as per gastric cancer guidelines. For type II
cancers, the extent would depend on the prevailing philosophy of
the surgeon; on the likely behavior of the tumor as predominantly
esophageal or gastric cancers.1.2 Esophago-
Gastrectomy
for Esophagogastric
Junction Cancers
Simon Law