Surgical resection for cancer of the cardia

From the pathogenic and therapeutic point of view, adenocarcinomas of the e sophagogastric junction (AEG) should be classified into adenocarcinoma of t he distal esophagus (Type I), true carcinoma of the cardia (Type II), and s ubcardial carcinoma (Type III). This classification can be easily performed by summarizing the information available from contrast radiography, endosc opy, and intra-operative findings; it allows comparison of data between var ious centers and facilitates the choice of surgical therapy. A complete rem oval of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the esophagogastric junc tion. In patients with potentially resectable, true carcinoma of the cardia (AEG Type II), this can be achieved by a total gastrectomy with transhiata l resection of the distal esophagus and en bloc removal of the lymphatic dr ainage in the lower posterior mediastinum and along the celiac axis and sup erior border of the pancreas. This approach is associated with lower morbid ity and provides equal long-term survival as compared to the more radical t ransmediastinal or abdominothoracic esophagogastrectomy. Whether a routine splenectomy for lymphadenectomy in the splenic hilus offers a survival bene fit in these patients is questionable. In patients with early tumors staged as uT1 on pre-operative endosonography, a limited resection of the proxima l stomach, cardia, and distal esophagus with interposition of a pedicled is operistaltic jejunal segment appears justified since this procedure allows a complete tumor removal with adequate lymphadenctomy and offers excellent functional results. Multimodal therapy with pre-operative polychemotherapy or combined radio-chemotherapy appears to offer a significant survival bene fit in patients with locally advanced tumors. With this tailored approach, extensive pre-operative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept. (C) 1999 Wiley-Liss, Inc.