Kazuo Koyanagi, MD, PhD1, Soji Ozawa, MD, PhD1, Kentaro Yatabe, MD1, Yamato Ninomiya, MD1, Miho Yamamoto, MD1, Akihito Yamamoto, MD1, Yuji Tachimori2. 1Department of Gastroenterological Surgery, Tokai University School of Medicine, 2Cancer Care Center, Kawasaki Saiwai Hospital
Aim: Based on the distribution of lymph node (LN) metastasis and LN recurrence of Siewert type II adenocarcinoma, appropriate surgical procedure was investigated, and also minimally invasive surgery for Siewert type II adenocarcinoma was introduced.
Methods: One hundred and sixty-eight patients with Siewert type II adenocarcinoma who underwent surgery without any neoadjuvant therapy between 2001 and 2016 were enrolled. Metastatic stations and recurrent LN sites were classified into five zones; cervical, upper/middle/lower, mediastinal, and abdominal zones. After investigating the correlation between LN metastasis or recurrence and esophageal invasion length (EIL) of the tumor, we have introduced a laparoscopic and thoracoscopic surgery for Siewert type II adenocarcinoma since 2018.
Results: Overall LN metastasis or recurrence in the cervical, upper/middle/lower, mediastinal LN zones were detected in 4, 8, 11, and 25 patients, respectively. Overall LN metastasis or recurrence in the abdominal LN zone was detected in 87 patients, however, metastasis or recurrence in No. 4 LN (LN along the short and left gastroepiploic artery) station was detected in only one patient. Siewert type II patients with an EIL of more than 25mm had a higher incidence of more advanced stage (P < 0.001) and more overall metastasis or recurrence rate in the upper (P = 0.01), middle (P < 0.001), and lower (P = 0.002) mediastinal zones than those with an EIL of less than or equal to 25mm. Based on these retrospective results, a laparoscopic and thoracoscopic surgery including the mediastinal LN dissection and intrathoracic reconstruction using gastric conduit have been introduced for Siewert type II tumors with invasion to the thoracic cavity. Prone position and overlap anastomosis for reconstruction were used during thoracoscopic procedure. We have conducted this procedure in three patients. Mean clinical EIL was 26mm, mean operative time was 587 min, blood loss was 268mL, and there were no intraoperative complications. Pathologically, mean length of proximal margin from the tumor was 63mm, and abdominal LN metastasis was detected in two patients, but no mediastinal LN metastasis were detected. Despite short follow-up period, no recurrence including LN recurrence were detected.
Conclusion: Appropriate area of LN dissection and reconstruction methods were investigated based on the analyses of distribution of LN metastasis once the tumor has invaded more than 25 mm to the esophageal wall in Siewert type II adenocarcinoma. Laparoscopic and thoracoscopic surgery should be less invasive and could be conducted safely.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93863
Program Number: P512
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster