Total esophagogastrectomy plus extended lymphadenectomy with transverse colon interposition: A treatment for extensive esophagogastric junction cancer

Abstract

Aim: To review the post-operative morbidity and mortality of total esophagogastrectomy (TEG) with second barrier lymphadenectomy (D2) with interposition of a transverse colon and to determine the oncological outcomes of TEG D2 with interposition of a transverse colon.

Methods: This study consisted of a retrospective review of patients with a cancer diagnosis who underwent TEG between 1997 and 2013. Demographic data, surgery protocols, complications according to Clavien-Dindo classifications, final pathological reports, oncological follow-ups and causes of death were recorded. We used the TNM 2010 and Japanese classifications for nodal dissection of gastric cancer. We used descriptive statistical analysis and Kaplan-Meier survival curves. A P-value of less than 0.05 was considered statistically significant.

Results: The series consisted of 21 patients (80.9% men). The median age was 60 years. The 2 main surgical indications were extensive esophagogastric junction cancers (85.7%) and double cancers (14.2%). The mean total surgery time was 405 min (352-465 min). Interposition of a transverse colon through the posterior mediastinum was used for replacement in all cases. Splenectomy was required in 13 patients (61.9%), distal pancreatectomy was required in 2 patients (9.5%) and resection of the left adrenal gland was required in 1 patient (4.7%). No residual cancer surgery was achieved in 75.1% of patients. A total of 71.4% of patients had a postoperative complication. Respiratory complications were the most frequently observed complication. Postoperative mortality was 5.8%. Median follow-up was 13.4 mo. Surgery specific survival at 5 years of follow-up was 32.8%; for patients with curative surgery, it was 39.5% at 5 years.

Conclusion: TEG for cancer with interposition of a transverse colon is a very complex surgery, and it presents high post-operative morbidity and adequate oncological outcomes.

Keywords: Esophagogastric junction cancer; Total esophagectomy; Total esophagogastrectomy; Total gastrectomy; Transverse colon interposition.

Figure 1

Lymph node dissection when performing total esophagogastrectomy.

Figure 2

Surgery specimen, which was dissected in the operating room after surgery.

Figure 3

Colon section at the origin of middle colic artery, preserving the marginal arcade.

Figure 4

Transverse colon interposition through the posterior mediastinum. Coloesophageal anastomosis and colojejunal anastomosis are shown lateral view.

Figure 5

Transverse colon interposition through the posterior mediastinum. Coloesophageal anastomosis and colojejunal anastomosis are shown front view.

Figure 6

Complications observed according to Clavien Dindo classifications.

Figure 7

Lymph node metastasis distribution. Only patients with esophagogastric junction cancer are considered. LN: Lymph node according to the Japanese classifications.

Figure 8

Cancer specific survival at 5 years, according to residual tumors.

Figure 9

Five year survival follow-up by tumor stage according to the TNM classifications.