The Clinical Reseach Of Surgical Approach And Length Of The Upper Margin For Type Ⅱ And Ⅲ Adenocarcinoma Of Esophagogastric Junction

[Objective] There is a continuing rise in the incidence of adenocarcinoma of esophagogastric junction (AEG) around the world nowaday. However, the prognosis is worse than that of distal gastric cancer. AEG patients in Asian countries are mainly typeⅡandⅢ. The uptimal surgical approach and appropriate length of upper margin for AEGⅡandⅢremain unclear, especially with the widespread use of stapler. This study aimed to establish a criterion for approach choice and verify its feasibility.[Materials and Methods] Patients of AEGⅡandⅢ, who received surgical treatment in the Department of Abdominal Surgery in Shanghai Cancer Hospital of Fudan University from March 1,2009 to February 29,2010, were analyzed. They had received Endoscopic ultrasonography(EUS),Upper gastrointestinal radiography(UGI), Multidetector CT (MDCT) and Cardiopulmonary function tests for preoperative examinations.Patients whose lengths of esophageal invasion<3 cm underwent abdominal approach, unless the patient's figure was not conductive to operation while others whose involvements≥3 cm selected the left thoracoabdominal incision unless patients could not tolerate thoracotomy. The lower edge of clamp was placed 4 cm above the tumor, and then the esophagus was cut off 0.6 cm below the clamp's lower edge to ensure a 5 cm-upper-margin. D2 lymphadenectomy was routinely done during the surgery, the ultimate goal of which was to achieve R0 resection. The information about surgery and pathology was collected, such as the tumor's location, surgical approach, exposure condition, operative time, extent of esophagogastric resection, extent of lymph node dissection, positive or negative margin, length of esophageal margin at different phages, postoperative complications, and length of stay. All the data was entered and analyzed by SPSS 17.0 software. P<0.05 was considered to be statistically significant. The advantages of the abdominal incision and the left thoracoabdominal incision were compared, and the same comparison was also done between typeⅡandⅢ.[Results] A total of 57 patients underwent palliative or radical surgery, including 47 males and 10 females.42 cases (73.7%) were typeⅡand 15 cases (26.3%) were typeⅢ. The average age was 61 (ranging from 40 to 78).11 patients underwent the left thoracoabdominal incision, including 1 patient plus left chest incision on the basis of abdominal incision, so just 46 cases accepted abdominal incision only. All 57 patients underwent surgery successfully with good exposure and safe anastomosis, except 1 case of abdominal incision added the chest incision because of special reasons. There was no operative death. The postoperative complication rate was low, and no serious lung infection, gastrointestinal bleeding, anastomotic leakage, and other serious complications happened. The rate of positive upper margin was 0. Regardless of the length of esophageal anastomotic ring, the average length of upper margin before resection was 3.65 cm(95%CI 3.44～3.85 cm).47 cases (82.5%) were up to standard and 10 cases sub-standard. The lengths of upper margin after removing of the specimen and after fixation were 1.95 cm and 1.20 cm. Therefore, the shrinkage rate after removing of the specimen and after fixation were 53.6% and 33.0%. There were significant differences in operative time and the length of esophageal invasion between abdominal group and thoracoabdominal group. But the length of upper margin at different stages, number of lymph node dissection, blood loss, early complication rates, total days of hospitalization and postoperative hospitalization showed no significant difference. Except the length of esophageal invasion, number of lymph node dissection, rate of total gastrectomy, there were no significant differences between TypeⅡandⅢ.[Conclusion] Integrated application of UGI, Gastroscope (including EUS) and MDCT before surgery can accurately define the type of AEG, and can obtain numerous information, like the length of esophageal invasion, the depth of invasion (T stage), lymph node metastasis, and curable possibility, etc. Combining with patient's figure (e.g. fat, thin, thoracic anteroposterior diameter, Xiphoid position, the width of sternum bottom corner, etc.), we can choose the surgical approach conveniently, rationally and effectively. For the patients of AEGⅡand AEGⅢ, a 5 cm-upper-margin is appropriate, and the way we use the stapler and cut off the esophagus was right. Grossly, the specimen should have an at least 2 cm-upper-margin to ensure a negative surgical margin.