Abdominothoracic Esophagohemigastrectomy

Abstract

The surgical approach toward adenocarcinomas of the esophagogastric junction (AEG) is still under debate. Siewert and Stein provided a system for classifying the tumors into three types based on topographical-anatomical criteria; this has been widely accepted in Europe and has had a direct impact on therapeutic strategies. Type I AEGs involve the distal esophagus and arise mostly in the intestinal metaplasia of Barrett’s esophagus, Type II originate at the anatomical cardia, and Type III are subcardial gastric carcinomas infiltrating the esophagogastric junction and distal esophagus from below.

In Europe patients with an AEG Type I carcinoma are treated with radical en-bloc esophagectomy and gastric tube reconstruction. In patients with AEG Type II, an extended gastrectomy or esophagogastrectomy is indicated. In the United States the standard surgical therapy in patients with AEG Types I and II is esophagectomy with hemigastrectomy, whereas the therapy for Type III carcinomas is similar to that in Europe. In some patients a tumor is operated on as an esophageal cancer, but definitive histology shows a gastric cancer, and vice versa.

In case of a tumor extension involving more than one quarter of the stomach and a 5-cm distal margin cannot be achieved, a total esophagogastrectomy with colonic interposition is advised.