Total meso-esophagogastrectomy in surgically resectable Siewert type II-III junctional gastric cancer: Safety and long term oncologic outcome

Abstract

Aim: To analyze our experience confronting meso-esophagogastric resection (transhiatally extended total gastrectomy en-bloc with its inviolate primitive dorsal and ventral mesenterium) to less radical planes of surgery (intra-mesoesophagogastric and muscularis propria planes), in the multimodal management of junctional Siewert II/III resectable gastric cancer. Methods: 138 patients with stage I-III/C type II-III Siewert junctional cancers were enrolled. Proximal and distal marginal clearance, closest meso-esophageal resection margin (CRM), volume in mm 3 of meso-esophageal tissue around the tumor, R0 resections rate, number of lymph nodes harvested and five years overall and disease-free survival were recorded for each plane of surgery. Results: Mortality and morbidity were 3.6% and 22.4% respectively; operative length was 235 ± 23 min.; mean blood loss was 195 ± 53cc. Mean meso-esophageal tissue volume including tumor was 35,157 mm 3 for meso-esophagogastric resections, 25,397 mm 3 for intra-mesoesophagogastric resections and 20,531 mm 3 for “muscularis propria” resections, all statistically significant (p 1mm and pN0 were associated with increased recurrence-free survival. Conclusions: When compared to less extensive planes of surgery, transhiatally extended total meso-esophagogastrectomy confers a survival advantage in the intermediate stages of Siewert type II-III junctional gastric cancer, increasing R0 resection rate, decreasing CRM < 1mm and enhancing lymph node harvesting, with consequent impact on loco-regional control and survival; differently, in the extreme stages (I and IIIC N + patients), total meso-esophagogastrectomy is ineffective in altering the standard oncologic outcome. In our experience, total meso-esophagogastrectomy proved to be safe and oncologically effective, especially in stage II-IIIA/B, representing a pivotal part of multimodal management of type II/III EGJ cancers.