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Ergebnisse der primär chirurgischen Therapie beim Adenokarzinom des ösophagogastralen Übergangs

Adenocarcinoma of the esophagogastric junction: prognostic factors and results of primary surgery

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Zusammenfassung

Einleitung

Klassifikationen und operative Strategien werden beim weltweit häufiger werdenden Adenokarzinom des ösophagogastralen Übergangs kontrovers diskutiert.

Methodik und Material

Wir untersuchten die Prognose von 225 Patienten mit Adenokarzinomen im ösophagogastralen Übergang (1986–2000) in Abhängigkeit vom Karzinomtyp (AEG I–III nach Siewert) und vom Resektionsverfahren (Ösophagektomie; Gastrektomie).

Ergebnisse

Karzinome vom Typ I, II und III fanden sich zu 32%, 42% bzw. 26% (R0-Resektionen: 65%, 69% bzw. 51%; p=0,039) mit 5-Jahres-Überlebensraten von insgesamt 29%, 31% und 14% (p=0,068) bzw. 40%, 41% und 27% bei den R0-Resezierten (p=0,771). Prognostisch relevant waren in univariaten Analysen die TNM-Klassifikation, das Tumorstadium und die R-Klassifikation (jeweils p<0,001); in multivariater Analyse der R-Status (p=0,003), das Verhältnis metastatisch befallener zur Anzahl präparierter Lymphknoten (p=0,012) und der LK-Status (p=0,027). Die Mehrzahl der R1-Resektionen (63%) betraf den seitlichen Resektatrand. Chirurgische, pulmonale und kardiale Komplikationen fanden sich zu 33%, 26% und 10%; die 30-Tages-Letalität betrug 4%.

Schlussfolgerung

Die R0-Resektion ist ein wichtiger prognostischer Parameter. Resektionsverfahren mit unterschiedlichen endoluminalen Sicherheitsabständen können die Häufigkeit postoperativer R1-Situationen jedoch nur teilweise beeinflussen, da die Mehrzahl (>60%) den seitlichen Resektatrand betrifft.

Abstract

Introduction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide, and classification systems and resection procedures are being controversially discussed.

Methods and patients

We report on 225 AEG patients undergoing primary resection in our unit (1986–2000) with a special focus on perioperative morbidity, mortality, and long-term prognosis under consideration of the AEG type (Siewert classification) and operative procedure performed (subtotal esophagectomy with proximal gastric resection in AEG I, total gastrectomy with distal esophageal resection in AEG II and AEG III).

Results

Types I, II, and III carcinomas were found in 32%, 42%, and 26% of the patients, respectively, with R0 resections in 65%, 69%, and 51% (P=0.039). The overall 5-year survival rates were 29%, 31%, and 14% (P=0.068), respectively; in R0-resected patients, they were 40%, 41%, and 27% (P=0.771). In univariate analysis, the TNM classification (P<0.001), R classification (P<0.001), and tumor stage (P<0.001) were relevant prognostic factors. In multivariate analysis, only the R classification (P=0.003), LN ratio (P=0.012), and N stage (P=0.027) were independent prognostic factors. In 35 of 177 patients resected with curative intent, R0 resections could not be achieved, mainly because of residual tumor in the circumferential plane (22/35=63%). Only in 37% of cases (13/35) was the R1 situation due to exclusive positive oral or aboral resection margins. Therefore, in only 7% of all patients resected with curative intent (13/177) did the question arise of whether the R1 resection could have been avoided by a different surgical approach. Surgical, pulmonary, and cardiac complications were found in 33%, 26%, and 10%, respectively. The mortality within 30 days was 4%.

Conclusions

Failure of R0 resection in patients treated with curative intent is mostly caused by residual tumor in the circumferential plane. Therefore, different surgical approaches with varying oral and aboral resection margins are of minor importance for reducing the frequency of R1 resections. Downstaging of tumors by neoadjuvant treatment may increase the R0 resection rate.

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Authors and Affiliations

  1. Klinik für Allgemein- und Unfallchirurgie, Klinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf

    N. M. Bösing, J. W. Heise, P. E. Goretzki &  H.-D. Röher (em. Direktor der Klinik für Allgemein- und Unfallchirurgie, Klinikum der Heinrich-Heine-Universität Düsseldorf)

  2. Institut für Pathologie, Klinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf

    M. Sarbia

  3. Klinik für Allgemein- und Unfallchirurgie, Klinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf

    H.-D. Röher (em. Direktor der Klinik für Allgemein- und Unfallchirurgie, Klinikum der Heinrich-Heine-Universität Düsseldorf)

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  1. N. M. Bösing
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  2. J. W. Heise
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  3. P. E. Goretzki
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  4. M. Sarbia
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  5. H.-D. Röher
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Bösing, N.M., Heise, J.W., Goretzki, P.E. et al. Ergebnisse der primär chirurgischen Therapie beim Adenokarzinom des ösophagogastralen Übergangs. Chirurg 75, 1088–1097 (2004). https://doi.org/10.1007/s00104-004-0840-x

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