# Siewert II esophagogastric junction cancer: total gastrectomy or esophagectomy?

## TL;DR

This study compares two surgical approaches for Siewert II esophagogastric junction cancer, finding that total gastrectomy with distal esophagectomy may offer better quality of life without compromising outcomes.

## Contribution

Proposes a stepwise surgical strategy for Siewert II tumors that prioritizes lower morbidity while maintaining oncologic safety.

## Key findings

- 26 out of 38 patients underwent total gastrectomy with distal esophagectomy (TGDE), with no significant differences in outcomes compared to TEPG.
- TGDE is suggested as a less morbid option that avoids unnecessary esophagectomies without compromising oncologic results.
- Intraoperative frozen sections guide the decision to perform TGDE or TEPG based on margin status.

## Abstract

The surgical approach for esophagogastric junction cancers (EJC), Siewert II, has been controversial regarding margin control, reconstruction, and lymphadenectomy extension. Therefore, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging.Both surgical strategies are possible and have precise indications in each case. The TGDE may offer the best long-term quality-of-life perspective with less morbidity. This study suggests a stepwise strategy to approach lesions in EGJ, addressing lower morbidity since it prioritizes TGDE, grants a free margin, and does not jeopardize oncologic outcomes.Among 38 Siewert II patients, 26 (69%) underwent TGDE and 12 (31%) underwent TEPG, and regardless of the trend toward higher complication rates, positive margins, and shorter overall survival in the TEPG group, no statistically significant differences were detected.

The surgical approach for esophagogastric junction cancers (EJC), Siewert II, has been controversial regarding margin control, reconstruction, and lymphadenectomy extension. Therefore, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging.

Both surgical strategies are possible and have precise indications in each case. The TGDE may offer the best long-term quality-of-life perspective with less morbidity. This study suggests a stepwise strategy to approach lesions in EGJ, addressing lower morbidity since it prioritizes TGDE, grants a free margin, and does not jeopardize oncologic outcomes.

Among 38 Siewert II patients, 26 (69%) underwent TGDE and 12 (31%) underwent TEPG, and regardless of the trend toward higher complication rates, positive margins, and shorter overall survival in the TEPG group, no statistically significant differences were detected.

The mainstream curative-intent treatment for resectable and nonmetastatic EGJ cancers is surgery, and often, in combination with chemotherapy, according to clinical and pathologic staging. In the case of Siewert II tumors, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging, with each direction usually excluding the other.

Both surgical strategies are possible and have precise indications in each case. The TGDE may offer the best long-term quality-of-life perspective with less morbidity. This study suggests a stepwise strategy to approach lesions in EGJ, addressing lower morbidity since it prioritizes TGDE, grants a free margin, and does not jeopardize oncologic outcomes.

The surgical approach for esophagogastric junction cancers (EJC), Siewert II, has been controversial regarding margin control, reconstruction, and lymphadenectomy extension. Therefore, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging, with each direction usually excluding the other. Historically, complication rates for TEPG are higher, affecting further systemic treatment and long-term outcomes.

The aim of this study was to describe a surgical strategy for approaching tumors such as Siewert II EGJ, with the intraoperative decision to perform total gastrectomy with lymphadenectomy D2 or esophagectomy with lymphadenectomy based on intraoperative frozen sections.

All patients underwent laparotomy, beginning with greater curvature detachment while preserving the right gastroepiploic, right and left gastric arteries; dissection of the esophageal hiatus for node harvesting; and transection of the distal esophagus and its frozen section. TGDE was preferred if the proximal margin of the distal esophagus was negative; TEPG and gastric tube reconstruction were performed through transhiatal access if the margin was positive.

Among 38 Siewert II patients, 26 (69%) underwent TGDE and 12 (31%) underwent TEPG, regardless of the trend toward higher complication rates, positive margins, and shorter overall survival in the TEPG group, no statistically significant differences were detected.

Although no significant differences in morbidity between the two procedures were noted, type II errors could be a possible cause. This study suggests that unnecessary esophagectomies can be avoided without jeopardizing surgical or oncologic outcomes by opting for a less morbid procedure.