Minimum Esophageal Resection Length to Ensure Negative Proximal Margin in Total Gastrectomy for Gastric Cancer

Abstract

Objective: To identify the minimum length of esophageal resection to ensure a pathologically negative proximal margin (PM) in total gastrectomy for gastric cancer. Background: In total gastrectomy, a certain esophageal length is resected to obtain a pathologically negative PM because of the possibility of unexpected pathological esophageal invasion. However, a recommendation regarding the esophageal transection site in total gastrectomy has not been established. Methods: The data of patients who underwent total gastrectomy for gastric cancer from 2005 to 2018 were collected. We evaluated the length of unexpected pathological esophageal invasion (esophageal ΔPM) in each type of disease and each location of the gross proximal tumor boundary (PB) using the length between the PB and the esophagogastric junction (PB-EGJ length). Results: Of the 1005 patients eligible for this study, 277, 196, and 532 had cT1, cT2–4 expansive (Exp), and cT2–4 infiltrative (Inf) growth patterns, respectively. In cT1 and Exp, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >1 cm, whereas pathological esophageal invasion occurred in 20.0% of cT1 and 32.7% of Exp when the PB-EGJ length was ≤1 cm. The esophageal ΔPM was <1 cm. In Inf, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >3 cm, whereas pathological esophageal invasion occurred in 17.4% of patients when the PB-EGJ length was ≤3 cm. The esophageal ΔPM was <2 cm. Conclusions: New recommendations regarding the esophageal resection length required to ensure a pathologically negative PM in total gastrectomy are herein proposed.

Adequate gross resection margin length ensuring pathologically complete resection in gastrectomy for gastric cancer: A systematic review and meta‐analysis

“…We further excluded 124 studies because of the protocol ( n = 3), review articles ( n = 37), disparate outcomes ( n = 74), and irrelevant exposures ( n = 10). Finally, 13 retrospective studies (seven from Japan, three from South Korea, one from the United States, one from Italy, and one from France) were included 3,20–31 . The PRISMA flowchart of the literature assessment is shown in Figure 1.…”

“…Thus, we should transect the esophagus or stomach over the ΔRM apart from the gross tumor boundary to obtain a pathologically negative RM. For the analyses of ΔRM, the histograms were constructed with the horizontal axis corresponding to the range of ΔRM length in 5–10 mm increments and the vertical axis corresponding to the number of patients 20–23 . Then, based on this histogram, the possible incidence of pathologically positive RMs by respective “gross RM length” in each disease type was calculated or extracted from the studies.…”

“…Finally, 13 retrospective studies (seven from Japan, three from South Korea, one from the United States, one from Italy, and one from France) were included. 3,[20][21][22][23][24][25][26][27][28][29][30][31] The PRISMA flowchart of the literature assessment is shown in S1).…”

“…The characteristics of the six studies are shown in Table 3. These studies evaluated the ΔRM (discrepancy between the gross and pathological RM lengths in gastrectomy), including four studies [20][21][22][23] from our institute that evaluated the possible incidence of a pathologically positive RM associated with each ΔRM. We also adapted the same concept in the remaining two studies, 29,30 both from South Korea, of which Berlth et al 30 evaluated the ΔRM in the proximal RM for pT2-4 disease.…”

“…Additionally, four studies [20][21][22][23] from our institute performed subgroup analyses (Table 4). Hayami et al 20…”