Choice Of Surgical Procedure In Siewert Type ? Adenocarcinoma Of Esophagogastric Junction

Objectives:Survival rates between patients with Siewert II adenocarcinoma of esophagogastric junction(AEG)who underwent radical total gastrectomy and proximal subtotal gastrectomy were compared,then the necessity of radical total gastrectomy was tested in view of suprapyloric and subpyloric lymph nodes.Methods:A total of 169 patients who diagnosed with type II AEG and underwent the D2 radical surgery in the First Affiliated Hospital of Xiamen Universtiy between April,2010 and July,2017 was searched and their clinicopathological information was retrospectively collected.After adjusting the baseline,survival rates between patients with Siewert ? adenocarcinoma of esophagogastric junction(AEG)who underwent radical total gastrectomy and proximal subtotal gastrectomy were compared,then stratified analysis based on tumor size(? 4 cm vs.<4 cm),T stage(T1+T2 vs.T3+T4),TNM staging(Stage ? vs.Stage ? vs.Stage ?)and differentiation(G1+G2 Vs.G3)were carried out between the two groups.With the postoperative pathology being as "gold standard",the incidence rate and ratio of peripyloric lymph node metastasis were computed.In patients who underwent total gastrectomy,the survival rates between the group with postive peripyloric lymph node and the group with negative peripyloric lymph node were compared.Lastly,the risk pathological factors of peripyloric lymph node metastasis were identified.Results:(1)138 patients(58 patients who underwent radical total gastrectomy and 80 patients who underwent proximal subtotal gastrectomy)was successfully followed up.The one-year survival rate and three-year survival rate were 75.5%and 56.7%in the total gastrectomy group,and were 56.7%and 55.6%in the proximal gastrectomy group,with no significant difference being found(P = 0.2 and 0.91,respectively).Survival curves and the Log-rank univariate analysis suggested that there was no advantage in overall survival between the two surgical approaches(HR = 1.28,95%CI:0.59-2.74,P = 0.34).(2)No difference was observed in each stratified analysis based on tumor size,T stage,TNM stage and differentiation(all P values>0.05).(3)In the group of total gastrectomy,11 cases with peripyloric lymph node metastasis was observed in 72 patients and the incidence rate of metastasis was 15.3%.In the all 383 resected peripyloric lymph nodes,52 lymph nodes was positive and the rate of positive lymph node was 13.6%.(4)After Group ?(patients with postive peripyloric lymph node)and Group ?(patients with negative peripyloric lymph node)being divided based on the presence of peripyloric lymph node metastasis,the mean survival time for Group ? and Group ? were 15.0± 3.2 and 32.8 ± 2.6 months(P<0.001).The one-year survival rates for Group I and Group ? were 34.0%and 67.0%(P<0.001);The three-year survival rates were 21.4%and 64.8%respectively(P = 0.01).Survival curves and Log-rank univariate analysis suggested the presence of peripyloric lymph node metastasis was significantly associated to the overall survival(Group ? vs.Group ?:HR=3.0,95%CI:2.3-4.0,P-0.02).(5)Tumor size was an important risk factor for peripyloric lymph node metastasis(36.8%for? 4cm and 0 for<4cm,P<0.001).Conclusions:Compared with proximal gastrectomy,extensive radical total gastrectomy could not bring more survival benefit in patients with Siewert type ? AEG.The positive peripyloric lymph nodes,whose dissection had limited utility,indicated poor diagnosis for Siewert type ? AEG patients.Tumor size was an important risk factor for peripyloric lymph node metastasis in Siewert type ? AEG patients.