Surgery for GEJ Cancers
Prof SM Chandramohan
Surgery for GEJ tumours continues to remain debatable even in 2019 due to various issues which govern the management philosophy. The debate starts from the fact whether it should govern only adenocarcinoma or to include SCC which is common in Asian population, but can be in anatomical GE Junction. Though Siewert’s classification was the one followed by many for several years, it is being debated now whether it satisfies all the criteria especially in long segment and impassable tumours where epicentre couldn’t be defined. The same is applicable even to Japanese classification. The two other major factors which decides the surgical option include: the geographical location of the surgical team and the area they have specialised in: Thoracic Surgeons or Gastric Surgeons.
Whatever be the country and the specialty, few factors remain constant to define the surgery as optimum and appropriate. It depends upon the type of GEJ. The least controversial ones are the Type I or Esophagus Predominant; Type III or Gastric Predominant. Most of the controversy reviews around management of Type II or EG Tumours.
The Key factors which are to be considered while operating on GEJ tumours are:
- The Extent of Resection in Esophagus and Stomach with specific reference to the margins depending upon the procedure chosen.
- The extent of lymphadenectomy depending upon the site of the tumor.
- The access or the surgical approach: Transabdominal, Abdominothoracic, abdominal and thoracic, abdominal, thoracic and cervical.
- The technique of reconstruction depending upon the type of resection.
- Changing trend in the access from open surgery to Minimally Invasive and Robotic Procedures.
- Morbidity and Quality of life issues depending upon the surgical procedure chosen.
Analysis on the world wide trends in Surgical techniques shows that Esophagectomy is followed by many for Type I or Esophagus predominant tumours; Extended gastrectomy for Type II or EG tumours – some favouring Transabdominal and few favouring thoraco-abdominal approach; Gastrectomy for Type III or Gastric predominant tumours.
There can be rare situations where both esophagus and stomach are removed for GEJ tumors and colon is used as a conduit.
The specific issue which has to be addressed is in situations where a proximal gastrectomy is performed especially in Type II or EG tumours, as there are many factors which influence both short term and long term outcomes especially in terms of QoL.
The type of resection and access is also influenced by whether it is being managed by Esophageal Surgeons or Gastric Surgeons. In our country it depends upon – Thoracic Surgeons, GI surgeons, Onco Surgeons or General Surgeons.
In conclusion, the type of Surgical Procedure chosen should be Oncologically acceptable, with minimum morbidity , good QoL and long term outcome.