Discuss about surgical principles, techniques and evidences regarding surgical treatment options for esophageal and gastric cancer

1. Surgical Principles and Evidence
based Surgical Management of
Esophageal and Gastric Cancers
Dr Pradeep Dhanasekaran
Consultant Surgical Oncologist
Gleneagles Global Health City,
Chennai

2. Surgery has always been considered the most effective way of ensuring both
local-regional control and long-term survival for patients with tumor invading into or
beyond the submucosa with or without lymph node involvement.
Multimodality treatment is the standard nowadays
Premalignant disease
T1 disease
T2 and above, N any disease
Esophageal Cancer

3. Barrett Esophagus with HGD
Rationale:
High grade dysplasia – risk of invasive
adenocarcinoma is 6% per year
Resected specimens for HGD
reported to have unidentified invasive
cancer in 40%
1. Esophagectomy
Against:
Majority not develop invasive carcinoma
in lifetime
Morbid procedure
Local ablative and Endoscopic
procedures can achieve cure
2. Local Ablative Methods:
Radiofrequency Ablation and Photodynamic therapy
3. Endoscopic Resection:
Endoscopic Mucosal Resection (EMR)
mucosal lesion T1a, no ulceration, not poorly differentiated, <2cm, no LVI
Endoscopic Submucosal Dissection (ESD)
T1b with superficial submucosal invasion (SM1)

4. T2 and above, N any
Multimodality treatment
Surgery
Chemotherapy
Radiotherapy
Neoadjuvant chemoradiation followed by Surgery
is the standard treatment nowadays

5. Surgical Resection
Open or Minimally
Invasive?
Transthoracic or
Transhiatal?
Extended
lymphadenectomy
or not?

6. Cervical Phase
Abdominal Phase
Orringer’s Transhiatal Esophagectomy

7. Blind Mediastinal dissection

8. 1st abdominal phase
2nd thoracic phase
Anastomoses intrathoracic
1st thoracic phase
Next Abdominal and neck
Cervical Anastomoses
McKeown’s
Ivor Lewis
Transthoracic Esophagectomy

9. Transthoracic or Transhiatal?
Transhiatal Transthoracic
• No Thoracotomy incision –
less pain, pulmonary
complications
• Less morbidity and mortality
• No intrathoracic
anastomoses
• Cervical anastomoses –
chance of only salivary leak
• Poor visualisation of upper
and mid esophageal tumors
• Increased anastomotic leak
and stricture
• More prone for RLN injury
Advantages
Disadvantages
• Direct visualisation
• Wider resection with
adequate radial margin
• Thorough lymph node
dissection
• Trend towards improved
survival
• Thoracotomy
• Morbid
• Lung complications
• Intrathoracic anastomotic
leak - Mediastinitis

10. Surgical & Oncological Outcomes
Transhiatal Transthoracic
Largest Series by Orringer
1525 patients
82% Lower third
18% Mid and Upper third
79% Adenocarcinoma
21% Squamous
Anastomotic leak 12%
RLN palsy 4.5%
Mortality 3%
5 year survival 25% 5 year survival 26%
Perioperative mortality
1.4% to 9%

11. RCT Evidence
5 Year OS 34% vs 36%

12. Meta- Analysis

13. Extended lymphadenectomy or not?
Lymph Nodal Stations

14. International Society for Diseases of the
Esophagus (ISDE) Classification

15. Studies comparing 3 Field vs 2 Field Lymphadenectomy

16. Open or Minimally Invasive?

18. Netherlands Study, Published in 2017

19. French Study, Published in 2019 and 2021

20. Netherlands Study, Published in 2019 and 2020

21. Post Chemoradiation – Extended
Lymphadenectomy is not necessary
Carcinoma Esophagus
Neoadjuvant Chemoradiation followed by
surgery is the standard for T3, N+ lesions
Hybrid Minimally Invasive Esophagectomy is
considered standard
Early lesions – Endoscopic resection or
Esophagectomy is standard (HMIE preferred)

22. Surgical Resection
Open or Minimally
Invasive?
Extent of Gastric
Resection?
Extent of
lymphadenectomy?
Splenectomy?
Bursectomy?
Gastric Cancer

23. Gastric
surgery
Curative
Standard
Modified or
Extended
Non
curative
Palliative
Reductive
At least 2/3rd of stomach
resection plus D2 dissection
Modified – extent of gastric
resection or lymph
dissection reduced
Palliate the symptoms of
bleeding or obstruction
To reduce tumor bulk in
presence of incurable factors
Gastric Surgery

24. Extent of Gastric
Resection?
Distal
Gastrectomy
Total
Gastrectomy
Proximal
Gastrectomy
Segmental
Gastrectomy
Pylorus
preserving
Local
Resection
Margins at Gastric
Resection?
Distal Margin 1 cm enough
Proximal
Margin
2 cm enough for T1 lesion
3 cm for Bormann
Types I and II
5 cm for Bormann
Types III and IV
• Body and proximal stomach tumors
• Greater curvature tumors
• Splenectomy required
• Pancreas invasion – needing
pancreatosplenectomy

25. Bormann’s
classification

26. Impact of the extent of surgical resection
on survival of Distal Gastric cancer
3 small RCTs compared Total vs Partial for distal
gastric cancer
• Overall morbidity, mortality and oncological
outcomes similar
• Total gastrectomy associated with Inferior
long term quality of life
• Risk of remnant gastric cancer – 0.4% to 2.5%
Distal Gastric cancers – a gastric preserving R0 approach minimize the
risk of sequelae of Total gastrectomy like early satiety, weight loss and
need for Vit B12 supplementation.

27. Proximal vs Total Gastrectomy for
Proximal Gastric cancer
Meta-analyses of 1 RCT, 23 studies
• No significant diff in OS between two
• Increased reflux symptoms & anastomotic
stenosis in PG
• LN harvest better with Total gastrectomy
• Risk of remnant gastric cancer – 3.6% to 9.1%
Proximal Gastric cancers – although no OS difference noted
Reflux symptoms, anastomotic stenosis, risk of LN mets to station 5, 6
and remnant stomach cancer, Difficult endoscopy during follow up –
all these to be considered before looking for benefits of gastric
preservation.

28. Nodal stations

30. D levels

31. D1 dissection
T1a tumors not meeting criteria for EMR/ESD
D1 (+) – T1N0 tumors other than above
D2 - Standard for T2 to T4, N+
D2 (+) – Extended surgery
No.10 – upper stomach involving greater curve
No.14v – distal stomach with Station 6 nodal mets
No.13 – stomach cancer invading duodenum
No.16 – nodal involvement after NACT
Extent of D? and When?

32. Technique of D2 Gastrectomy
1. Decolement 2. Infra pyloric dissection

33. 3. Suprapyloric dissection 4. Duodenal transection
5. D2 nodal clearance

34. Reconstruction
following Distal
Gastrectomy

35. Reconstruction
following Total
Gastrectomy

36. D1 vs D2 Lymphadenectomy (5 RCTs)
1988, Cape Town Trial
43 patients
Significant morbidity with D2
5 yr OS – no difference
1994, PWH Hongkong Trial
55 patients
Significant morbidity with D2
Decreased median OS with D2
2004, Italian GCSG Trial
160 patients
No sig diff in operative morbidity, mortality
No survival advantage with D2

37. 2 RCTs MRC UK Trial, 1999 Dutch GC trial, 1999
D1 D2 D1 D2
Number 200 200 380 331
Operative
mortality
6.5% 13% 4% 10%
Post op
Complications
28% 46% 25% 43%
5 year OS 35% 33% 45% 47%
15 year Follow up:
15 year Overall survival : 21% 29%
Gastric cancer death rate : 48% 37%
Loco regional recurrence rate: 22% 12%
D2 dissection – Lower Locoregional recurrence rates and Gastric cancer related deaths
Pancreas and Spleen preserving D2 gastrectomy is Safer and Standard

38. Extended D2?
3 RCTs Polish Study, 2007 JCOG 9501, 2008 EASOG, 2008
D2 D2 + PAND D2 D2 + PAND D2 D2 + PAND
Number 141 134 263 261 134 134
Operative
mortality
2.2% 4.9% 0.8% 0.8% 1 pt 5 pts
Post op
Complications
27.7% 21.6% 20.9% 28.1%
5 year OS NR NR 69.2% 70.3% 52.6% 55%
PALN micromets 6%-33%
Extended D2 is not recommended

39. SPLENECTOMY???

40. BURSECTOMY???
N=1503, T3 T4a tumors Bursectomy No bursectomy
5 year OS 76.9% 76.7%
Pancreatic fistula 5% 2%
Morbidity 13% 11%

43. Minimally invasive Surgeries – yet to be
standardized.
Gastric Cancer
D2 Gastrectomy is the standard
Total – Stations 1 to 7, 8, 9, 11p and 11d and 12
Distal – Stations 1, 3,4sb,4d,5,6,7,8,9,11p & 12
No need splenectomy, bursectomy and
extended D2
Early GC – Endoscopic resection or D1
Gastrectomy

44. Thank You