The Approach for Advanced Gastric Cancer with Esophageal Invasion: which is Better, a Transthoracic or a Transabdominohiatal Approach?

Souya Nunobe, Shigekazu Ohyama, Masanori Tokunaga, Naoki Hiki, Tetsu Fukunaga, Yasuyuki Seto and Toshiharu Yamaguchi

Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital

Background: Recently, the transabdomino-hiatal approach (TAH) for advanced gastric cancer with esophageal invasion (AGCE) has been increasingly adopted after the results of a randomized control trial comparing between the transthoracic approach (TT) and TAH for AGCE was published. This study aimed to compare the treatment results between TAH and TT, and to examine the optimal approach for AGCE and the comparative efficacy of dissection of mediastinal lymph nodes. Methods: Eighty-one patients with AGCE, comprising 51 cases treated by the TT approach and 30 by the THA approach, were reviewed clinicopathologically. Results: There were more patients with advanced clinical stage in the TAH group than in TT group (P=0.028). The operation time was significantly longer and intraoperative bleeding significantly greater in the TT group (P<0.001 and P=0.054, respectively). There were no significant differences in the clinicopathological findings, including the macroscopic type, depth of invasion, extent of lymph node metastasis, length of esophageal invasion, extent of mediastinal lymph node metastasis, pathological stage or morbidity between the two groups. Mediastinal lymph node metastases were found in 9 cases (18%) in the TT group and 6 cases (20%) in the TAH group. There was also no significant difference in the survival between the two groups. Two of the 6 patients with mediastinal lymph node metastases in the TAH group showed survival of more than 4 years. Conclusion: The present study demonstrated that TAH might be a useful approach for AGCE, as the therapeutic results and morbidity in the TAH group were comparable to those in the TT group despite the larger number of advanced cases. Also, dissection of mediastinal lymph node appears to be an essential technique, even in patients treated by the TAH approach, since some cases of AGCE with mediastinal lymph node metastases showed longer survival.

Key words
advanced gastric cancer, esophageal invasion, transthoracic approach, transabdominohiatal approach

Reprint requests
Souya Nunobe Department of Surgery, Metropolitan Komagome Hospital
18-22 Honkomagome 3-chome, Bunkyo-ku, 113-8677 JAPAN

Accepted
December 17, 2008

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