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To clarify the optimal operative procedure for gastric adenocarcinoma involving the esophago-gastric junction (EGJ), we investigated 49 cases with an upper gastric cancer invading the esophagus who underwent surgical treatment in our department during the period from 1991 to 2000. According to Siewert's classification, there were 21 cases with a type II tumor, and 28 cases with a type III tumor. Twenty-five cases underwent surgery through an abdominal approach only. The remaining 24 cases were operated on via a left thoraco-abdominal approach. Eight (33%) of 24 cases who underwent extended lymphadenectomy through a left thoraco-abdominal approach had lower mediastinal lymph node metastasis. Metastasis was observed in cases with cancer invasion more than 2 cm from the EGJ. There were 6 cases with a T1 tumor, 6 with a T2 tumor, 27 with a T3 tumor, and 10 with a T4 tumor. Incidences of lymph node metastasis were 0% for T1, 67% for T2, 81% for T3, and 80% for T4. Proximal gastrectomy was performed in 6 cases at the early stage and in 10 cases at the advanced stage with distant metastasis (M1). Total gastrectomy was done in 33 cases at the advanced stage, and 3 of these 33 cases had metastasis to the parapyloric lymph nodes. We performed combined resection of the body and tail of the pancreas and the spleen in 7 cases. One of these 7 cases had direct invasion to the pancreas and 6 cases had remarkable metastasis to the lymph nodes along the splenic artery. Splenectomy preserving the pancreas was done in 24 cases. The incidences of metastasis of the lymph nodes along the splenic artery and the splenic hilum were 25% and 17%, respectively. We performed partial resection of the diaphragm surrounding the esophageal hiatus in 15 cases through a left thoraco-abdominal approach. Six cases had metastasis to the diaphragm and nine cases had direct invasion to the diaphragm. Tumors were stage I in 8 cases, II in 5 cases, III in 13 cases and IV in 23 cases, and the curability was categorized as A in 8 cases, B in 20 and C in 21. The overall 5-year-survival rate was 25%, and the rates according to cancer stage were 86% for stage I, 40% for stage II , 21% for stage III and 0% for stage IV. The 5-year survival rates of cases at stage II and III were 33% for cases using the left thoraco-abdominal approach and 28% for cases with the abdominal approach. Based on these results, we recommend distal esophagectomy with total gastrectomy, and occasional combined resection of the spleen and the diaphragm through a left thoraco-abdominal approach for advanced gastric adenocarcinoma involving the EGJ.

Surgery and Clinicopathological Features of Gastric Adenocarcinoma Involving the Esophago-Gastric Junction