Total adventitial resection of the cardia: ‘optimal local resection’ for tumours of the oesophagogastric junction

Abstract

The aim of an oesophagectomy for cancer is long-term cure because of the availability of effective non-surgical ways of palliating dysphagia.1 Long-term survival is affected negatively by the N, T and R0 stages. 2 The oncological principle underlying curative resection of solid tumours is complete local clearance. Surprisingly little is published about the local resection of oesophageal cancers yet there is much debate about the optimal surgical approach to the oesophagus, ie whether it should be done via the right chest, left chest, transhiatal or laparoscopic route. 3,4Altorki and Skinner described good long-term survival after an en bloc oesophagectomy in which he combined a radical local resection with a 2-3 field block dissection of lymph nodes.5 By focusing on the local resection of the primary tumour rather than the lymphadenectomy in rectal cancer, total mesorectal resection of the rectum has been shown by studies replicated across the world to be associated with superior local recurrence rates and long-term survival compared with other surgical techniques. 6Furthermore, the pathological processing of resected rectums with external inking and slicing the specimens transversely for assessment on large histopathology slides have helped both in setting standards for histopathology reporting and also in assessing the quality of surgical resection. An adequately performed total mesorectal resection of the rectum (judged both surgically and histopathologically) is now considered the optimal operation for patients with rectal cancer. 7 We adopted the principles of rectal cancer surgery (ie standard surgical dissection techniques of the primary tumour as well as standard pathological processing and reporting) and assessed the feasibility of applying them to oesophagogastric junction (OGJ) cancer. Little is published about the local resection of oesophageal cancers. We adopted the principles of rectal cancer surgery, ie standard surgical dissection techniques as well as standard pathological processing and reporting, and assessed the feasibility of applying them to oesophagogastric junction (OGJ) cancer. METHODS Over a two-year period consecutive patients with invasive cancers of the OGJ were studied. Following staging and neoadjuvant chemotherapy (NAC), a standard dissection defined as a total adventitial resection of the cardia (TARC) was performed. Standard histopathological processing involved external inking, photographing, transverse slicing and mounting of cut samples on megablocks. Hospital morbidity and mortality as well as survival at five years' follow-up were assessed. RESULTS Forty consecutive patients had a TARC for OGJ carcinoma. Of these, 32 were offered NAC. Introducing TARC did not result in increased morbidity or mortality. Twenty-seven patients (68%) had an R0 resection that was directly related to the tumour stage and significantly related to a response to chemotherapy. Sixteen patients (42%) were alive five years after their TARC operation. CONCLUSIONS Although the adventitia of the OGJ is n...

Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue

“…8 If the hiatal orifice after TARC was deemed too wide, the anterior tendinous part of the hiatus was repaired with size 0 Ethibond ® sutures (Ethicon, Somerville, NJ, US). Overtightening of the hiatus is avoided by 'sizing' the orifice with laparoscopic forceps.…”

Diaphragmatic hernia following oesophagectomy for oesophageal cancer - Are we too radical?

“…Surgery for oesophageal cancer is associated with considerable morbidity and mortality. This is not unexpected given the extent of intraabdominal and intrathoracic dissection required [7] , [8] .…”

“…In contrast to the lymphadenectomy, which has been widely described in the literature, surprisingly little is published regarding the recommended extent of the hiatal resection. Only Botha and colleagues attempted to define the “optimal” resection for oesophago-gastric junction tumours as total adventitial resection of the cardia (TARC), with a hiatal excision of 0.5 cm of diaphragmatic crus, in order to reach the anterior surface of the aorta [8] . In this prospective observational study conducted over a two-year period consecutive patients with invasive cancers of the OGJ were studied [8] Forty consecutive patients had a TARC performed and of these 32 were offered neoadjuvant chemotherapy.…”

Total meso-esophagogastrectomy in surgically resectable Siewert type II-III junctional gastric cancer: Safety and long term oncologic outcome

“…The esophagogastric junction grows within a mesodermal envelope which forms a "compartment" that Matsubara defines as distal mesoesophagus [5], analogous to the mesorectum, but different in the lack of a mesothelial fascia propria, hence, Botha defines its borders anteriorly with the post-pericardial fat-pad, posteriorly with the pre-arotic fascia, and states its excision as total adventitial resection of the cardia or TARC [14].…”

“…In 6-to 7-week embryo, caudally to the diaphragm, the esophagus is wrapped in a mesenchymal tissue forming its anterior and posterior mesentery [18] and thus its definitive meso-esophagus [13,14]. This "distal mesoesophagus" [5] has its boundaries in the tracheal carina on the top, the diaphragm on the bottom, the pre-aortic plane posteriorly, the pericardial fat-pad anteriorly, and the pulmonary ligaments laterally; all the fibrofatty tissues within this compartment must be completely removed "en-bloc" with the distal esophagus for a length of 8-10cm: dissection begins with detachment of the anterolateral surface of the meso-esophagus from the posterior pericardial fat-pad, up to the carina; then, the pre-aortic fascia is separated from the diaphragmatic hiatus up to the level of tracheal bifurcation; left dissection along the pulmonary ligament and left mediastinal pleura proceeds up to the inferior pulmonary vein and left main bronchus, removing all the left bronchial and subcarinal nodes; same dissection is carried out on the right side [23].…”