52 yrman presented with dysphagia of 6months and acid peptic symtoms for 3years. Now he drinks a glass of water to swallow solid food. He has lost 4 kgs of weight. Upper GI endoscopy showed ulcerative leision at the GE jn ,biopsy adenocarcinoma. CECT showed tumour at the GEjn extending in to the fundus of stomach,small perigastric glands at ge jn are present.
If resectable, superior polar gastrectomy & distal esophagectomy, According to Ivor-Lewis technique.
Regards,
Giorgio Vasquez.
Siewert type I and II are treated as esophageal cancers and Siewert type III as gastric carcinoma. More information regarding extent of lesion from anatomic GE junction will be valuable.
I would consent the patient for both. I would first create a gastric tube and dissect the hiatus to mobilise as much of distal oesophagus as possible into the abdomen. I would then do a proximal oesophageal transection and send the specimen for frozen section histology.
If proximal margin is negative, would resect the gastric tube and do a Roux-en-Y oesophagojejunostomy in the abdomen itself.
If proximal margin positive, would do an oesophagectomy - Ivor-Lewis would be my choice in this situation.
This is OGJ ADC, which is locally advanced, ( nodes). I would GI for NACT with EOX based regimen 3-4 cycles, and then take up for surgery ( proximal polar gastrectomy ).
Firstly realize echoendoscopy to precise any submucosal extension. Secondly a PET scan to rule out metastasis. Thirdly dose Her2 for a possible biotherapy.
Discuss neoadjuvant radiochimiotherapy according to in-depth extension and to nodes fixation.
Then, perform oesogastrectomy with high anastomosis to lessens probability and gravity of leakage.
Siewert type III
1. Laparoscopy
2. Jejunostomy temporary
3. Neoadjuvant treatment radio and chemotherapy
4. If advance disease total gastrectomy with distal esophagectomy transhiatal lympn nodes removal
5. If no advance disease 2 stage Yvor Lewis abdominal and thoracic approach
6. Paleative treatment if peritoneal disease
Soubds like a type 3 goj tumour so extended total gastrectomy would be standard. Care needs to be tKen to assess the amount of oesophageal involvement particualrly in signet ring cancers. What does laparoacopy / ct and PET imaging show ?