The esophagus can be divided into cervical, thoracic, and abdominal segments. Among them, those occurring in the abdomen or at the junction of the esophagus and stomach are mostly adenocarcinoma, which is closely related to long-term acid reflux. For treatment, partial esophagectomy and gastrectomy or enlarged gastrectomy are usually used, sometimes requiring open heart and sometimes not. Here, we use a real case to understand how to decide the surgical plan for abdominal segment esophageal cancer.
Visit experience
Mr. Wang, 58 years old, had a choking sensation on eating for more than 1 year, with obvious symptoms when eating solid, harder foods and no obvious trigger found; no vomiting, heartburn, abdominal pain, bloating, hoarseness, choking, black stool, etc.
Gastroscopy and pathological biopsy were performed at the local hospital, suggesting adenocarcinoma of the esophagogastric junction. Later, he came to Peking University Cancer Hospital in April 2016 and underwent enhanced CT, PET-CT, upper gastrointestinal tract imaging, and gastroscopy of the chest and abdomen. It was found that a bulging mass with mucosal erosion and roughness on the surface was seen from the ventral segment of the esophagus to the cardia area at 35-40 cm from the incisor, with no abnormal enlargement of the surrounding and systemic lymph nodes. The pathologic biopsy suggested a moderately low-differentiated adenocarcinoma, clinical stage III .
The doctor recommended that Mr. Wang undergo surgery as soon as possible.
Formulation of the plan and preoperative preparation
After admission to the hospital, Mr. Wang completed routine preoperative tests. The surgeon also actively communicated with him and his family about the surgery.
The doctor said:
Your lesion is located inferiorly, close to the stomach, and requires a transabdominal incision to remove a portion of the stomach and esophagus. This procedure has the advantages of repetitive exposure, good visualization, high resection rate, and complete lymph node dissection, and it does not require dissection of the diaphragm, which has less impact on respiratory function.
Intraoperatively and postoperatively, there may be some risk of complications, such as bleeding, adjacent tissue and organ damage, anastomotic fistula, and pulmonary complications, which need to be understood by you and your family beforehand. But rest assured, experienced surgeons will try to avoid these risks, and even if they do occur, the surgeon has a way to address them. In addition, surgery is not a panacea. After the lesion is removed, there may still be some residual cancer cells in the body, hidden in the blood or lymphatic system. Doctors need to refer to the post-operative pathology report and surgical records to make a comprehensive assessment. If the risk of lymph node metastasis is high, postoperative “adjuvant therapy” can be used to remove as many residual cancer cells as possible to consolidate the results of surgery and prevent recurrence and metastasis.
During the consultation, the doctor learned that Mr. Wang was a 20-year veteran smoker, so he was instructed to quit smoking for at least 2 weeks before the surgery to reduce the chance of pneumonia after the surgery.
Surgery went well
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On April 18, 2016, Mr. Wang underwent surgery. The surgeon made an incision in the middle of the upper abdomen to expose the diseased esophagus and observed that the tumor was located in the cardia region of the stomach and invaded upward into the ventral segment of the esophagus, about 3 cm in diameter, with the depth of infiltration confined to the plasma membrane.
The tumor was peeled off and the surrounding lymph nodes were cleared, and the surgery was completed successfully.
Postoperative recovery
On the 3rd day after surgery, Mr. Wang started to get out of bed and followed the preoperative talk to start rehabilitation: when awake, he should take deep breaths and actively cough up sputum every hour to promote lung reopening and smoothly cough up sputum to avoid lung infection; manage the nutrition tube, watch for changes in himself and the nutrition tube, and communicate with the doctor if there is blockage or discomfort such as diarrhea, bloating, nausea and vomiting.
For the first week after surgery, he was fed nasally, and after 1 week, he slowly began to eat a small amount of fluid via the mouth, and then gradually transitioned to a semifluid diet. After 1 to 2 weeks of feeding, he began to train swallowing by drinking 10 mL of honey or olive oil before eating and then swallowing soft buns in large bites to dilate the anastomosis. After the surgery 1 month or so, he began to return to his regular diet and followed the doctor’s instructions to eat smaller and more frequent meals, with appropriate additions of “special medical foods” between meals.
Review follow-up
Mr. Wang had regular follow-up examinations every 3 months for two years after surgery, and by April of this year, no recurrence of tumor metastasis was seen. The doctor told him that he could extend the review period to six months, and that he should seek medical attention at any time for any physical abnormalities.
Summary
In 2017, the American Joint Committee on Cancer (AJCC) released the 8th edition of the TNM staging criteria for esophageal cancer, which redefines Adenocarcinoma of Esophagogastric Junction (AEG) as a tumor centered no closer than 2 cm from the cardia.
Adenocarcinoma of the Esophagogastric Junction is anatomically unique, distinct from both esophageal and gastric cancer, but with characteristics of both. Its incidence is increasing worldwide year by year, but remains low in China. The prevalence of gastroesophageal reflux disease (GERD) is strongly associated with the risk of AEG, and patients with Barrett’s esophagus (a precancerous lesion of esophageal adenocarcinoma) require more intensive surveillance and screening for AEG.
The diagnostic staging of AEG has been the subject of much debate, and there is no accepted academic “gold standard” for treatment modalities. In general, the choice of surgical approach depends on the location of the tumor and the way the GI tract is reconstructed, the surgeon’s experience and practice, and the patient’s general condition. The principle is to ensure adequate surgical margins and adequate lymph node dissection to minimize the risk of postoperative recurrence and metastasis.
What you need to understand is that the key to improving AEG survival is still early detection and early treatment of the tumor. If you have frequent manifestations such as acid reflux, or a clear diagnosis of GERD or Barrett’s esophagus, you should be monitored regularly for progression and have regular gastroscopy to screen for esophageal cancer under the guidance of your doctor.
Disclaimer:
Tumor disease and treatment options are extremely complex, and treatment should be fully individualized, and this case does not represent a treatment decision for a “similar patient. Please seek professional advice from a competent physician regarding your specific treatment plan.