Stein H J, Feith M, Siewert J R
Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany.
Ann Chir Gynaecol. 2000;89(3):191-8.
Due to their borderline location between the stomach and esophagus the optimal surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial. Irrespective of the surgical approach a complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of surgical treatment of such tumors. Based on the experience with surgical resection of more than 1000 patients with adenocarcinoma of the esophagogastric junction we recommend an individualized surgical strategy guided by tumor stage and topographic location of the tumor center or tumor mass. This requires detailed preoperative staging and classification of tumors arising in the vicinity of the esophagogastric junction into adenocarcinoma of the distal esophagus (AEG Type I Tumors), true carcinoma of the gastric cardia (AEG Type II Tumors) and subcardial gastric carcinoma infiltrating the esophagogastric junction (AEG Type III Tumors). In patients with Type I Tumors transthoracic esophagectomy offers no survival benefit over radical transmediastinal esophagectomy, but is associated with higher morbidity. In patients with Type II or Type III tumors an extended total gastrectomy results in equal or superior survival and less postoperative mortality than a more extended esophagogastrectomy. In patients with early tumors, staged as uT1 on preoperative endosonography, a limited resection of the proximal stomach, cardia and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment allows a complete tumor removal with adequate lymphadenectomy and offers excellent functional results. Multimodal treatment protocols with neoadjuvant chemotherapy or combined radiochemotherapy followed by surgical resection appear to markedly improve the prognosis in patients with locally advanced tumors who respond to preoperative treatment. With this tailored approach extensive preoperative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.
由于食管胃交界腺癌患者的肿瘤位于胃和食管的交界边缘位置，其最佳手术策略存在争议。无论采用何种手术方式，完整切除原发肿瘤及其淋巴引流区域都应是此类肿瘤手术治疗的首要目标。基于对1000多例食管胃交界腺癌患者手术切除的经验，我们建议根据肿瘤分期以及肿瘤中心或肿瘤块的地形位置制定个体化手术策略。这需要对食管胃交界附近发生的肿瘤进行详细的术前分期和分类，分为远端食管癌（AEG I型肿瘤）、真正的贲门癌（AEG II型肿瘤）和浸润食管胃交界的贲门下胃癌（AEG III型肿瘤）。对于I型肿瘤患者，经胸食管切除术与根治性经纵隔食管切除术相比，并无生存优势，但并发症发生率更高。对于II型或III型肿瘤患者，扩大全胃切除术与更广泛的食管胃切除术相比，生存率相同或更高，术后死亡率更低。对于术前超声内镜检查分期为uT1的早期肿瘤患者，近端胃、贲门和远端食管的有限切除并插入带蒂顺蠕动空肠段，可实现肿瘤的完整切除和充分的淋巴结清扫，并能取得良好的功能效果。新辅助化疗或放化疗联合手术切除的多模式治疗方案，对于术前治疗有反应的局部晚期肿瘤患者，似乎能显著改善预后。采用这种定制方法时，广泛的术前分期对于适当选择合适的治疗方案变得至关重要。
