Esophagogastric junction adenocarcinomas: individualization of resection with special considerations for Siewert type II, and Nishi types EG, E=G and GE cancers

  • Arnulf H. HölscherEmail author
  • Simon Law
Review Article


For Siewert type II adenocarcinoma of the esophagogastric junction (AEG II), or similar tumors classified as Nishi EG, E=G, GE, the type of surgical resection and reconstruction should be individualized. Criteria for decision making mainly focus on the oral extent of esophageal infiltration, the cT and cN category and the functional status of the patient. For cT1/cT2 adenocarcinomas, which are non-poorly cohesive, intestinal type of Lauren Grading 1 or 2 without clinical signs of lymph node metastasis at the distal stomach, a limited transhiatal proximal gastrectomy with double tract reconstruction is recommended. For advanced adenocarcinomas, subtotal esophageal and proximal gastric resection with gastric pull-up or distal esophageal resection with total gastrectomy and esophagojejunostomy are competing procedures. Criteria for choosing the appropriate type of surgery are discussed.


Gastric cancer Esophageal cancer Adenocarcinoma of the esophagogastric junction Siewert classification Nishi classification 


Compliance with ethical standards

Conflicts of interest

The author declares that they have no competing interests.

Human and animal rights statement

This review article does not contain any studies with human participants performed by any of the authors.

Informed consent

Informed consent is not necessary.


  1. 1.
    Siewert JR, Hölscher AH, Becker K, Gossner W. Cardia cancer: attempt at a therapeutically relevant classification. Chirurg. 1987;58(1):25–32.Google Scholar
  2. 2.
    Hölscher AH, Schüler M, Siewert JR. Surgical treatment of adenocarcinomas of the gastroesophageal junction. Dis Esophagus. 1988;1:35–49.CrossRefGoogle Scholar
  3. 3.
    Nishi MKT, Akune T, et al. Cardia cancer-proposal of cancer in the esophagogastric junction (in Japanese). Geka Shinryo (Surg Diagn Treat). 1973;15:1328–38.Google Scholar
  4. 4.
    Kitagawa Y, Uno T, Oyama T, Kato K, Kato H, Kawakubo H, et al. Esophageal cancer practice guidelines 2017 edited by the Japan Esophageal Society: part 1. Esophagus. 2019;16(1):1–24. Scholar
  5. 5.
    Siewert JR, Feith JM, Werner JM, Stein JH. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1002 consecutive patients. Ann Surg. 2000;232(3):353–61. Scholar
  6. 6.
    Yamashita H, Seto Y, Sano T, Makuuchi H, Ando N, Sasako M. Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma. Gastric Cancer. 2017;20(Supplement 1):69–83. Scholar
  7. 7.
    Kurokawa Y, Takeuchi H, Doki Y, Mine S, Terashima M, Yasuda T, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study. Ann Surg. 2019. PubMed PMID: 31404008.CrossRefPubMedGoogle Scholar
  8. 8.
    Koyanagi K, Kato F, Kanamori J, Daiko H, Ozawa S, Tachimori Y. Clinical significance of esophageal invasion length for the prediction of mediastinal lymph node metastasis in Siewert type II adenocarcinoma: a retrospective single-institution study. Ann Gastroenterol Surg. 2018;2(3):187–96. Scholar
  9. 9.
    Jongerius EJ, Boerma D, Seldenrijk KA, Meijer SL, Scheepers JJ, Smedts F, et al. Role of omentectomy as part of radical surgery for gastric cancer. Br J Surg. 2016;103(11):1497–503. (PubMed PMID: 27550526. Epub 2016/08/24).CrossRefPubMedGoogle Scholar
  10. 10.
    Kim MC, Kim KH, Jung GJ, Rattner DW. Comparative study of complete and partial omentectomy in radical subtotal gastrectomy for early gastric cancer. Yonsei Med J. 2011;52(6):961–6. (PubMed PMID: 22028160; PubMed Central PMCID: PMCPMC3220242. Epub 2011/10/27).CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Mariette C, Carneiro F, Grabsch HI, van der Post RS, Allum W, de Manzoni G, et al. Consensus on the pathological definition and classification of poorly cohesive gastric carcinoma. Gastric Cancer. 2019;22(1):1–9. (Epub 2018/09/01. PubMed PMID: 30167905).CrossRefPubMedGoogle Scholar
  12. 12.
    Gutschow CA, Schröder W, Wolfgarten E, Hölscher AH. Merendino procedure with preservation of the vagus for early carcinoma of the gastroesophageal junction. Zentralbl Chir. 2004;129(4):276–81. (PubMed PMID: 15354248. Epub 2004/09/09).CrossRefPubMedGoogle Scholar
  13. 13.
    Zapletal C, Heesen C, Origer J, Pauthner M, Pech O, Ell C, et al. Quality of life after surgical treatment of early Barrett’s cancer: a prospective comparison of the Ivor-Lewis resection versus the modified Merendino resection. World J Surg. 2014;38(6):1444–52. Scholar
  14. 14.
    Hölscher AHBF, Hemmerich M, St Minot, Schmidt H. Double tract reconstruction following limited esophagogastric resection of AEG Types II and II adenocarcinomas. Zentralbl Chir. 2019;144:1–6.CrossRefGoogle Scholar
  15. 15.
    Aikou TNS, Shimazu H, et al. Antrum preserving double tract method for reconstruction following proximal gastrectomy. Jpn J Surg. 1988;18:114–5.CrossRefGoogle Scholar
  16. 16.
    Jung DH, Ahn S-H, Park DJ, Kim H-H. Proximal gastrectomy for gastric cancer. J Gastric Cancer. 2015;15(2):77–86. Scholar
  17. 17.
    Ahn SH, Jung DH, Son SY, Lee CM, Park DJ, Kim HH. Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer. Gastric Cancer. 2014;17(3):562–70. (PubMed PMID: 24052482. Epub 2013/09/21).CrossRefPubMedGoogle Scholar
  18. 18.
    Jung D, Lee Y, Kim D, Park Y, Ahn S-H, Park D, et al. Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer. Surg Endosc. 2017;31(10):3961–9. Scholar
  19. 19.
    Park JY, Park KB, Kwon OK, Yu W. Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients. Eur J Surg Oncol. 2018;44(12):1963–70. PubMed PMID: 30197164.CrossRefPubMedGoogle Scholar
  20. 20.
    KLASS-05 Multicenter prospective randomized controlled trial of laparoscopic proximal gastrectomy and laparoscopic total gastrectomy for upper third early gastric cancer KLASS-05,
  21. 21.
    Hosoda K, Yamashita K, Moriya H, Mieno H, Ema A, Washio M, et al. Laparoscopically assisted proximal gastrectomy with esophagogastrostomy using a novel “Open-Door” technique: LAPG with Novel Reconstruction. J Gastrointest Surg. 2017;21(7):1174–80. (PubMed PMID: 28025772. Epub 2016/12/28).CrossRefPubMedGoogle Scholar
  22. 22.
    Mine S, Sano T, Hiki N, Yamada K, Kosuga T, Nunobe S, et al. Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction. Br J Surg. 2013;100(8):1050–4. Scholar
  23. 23.
    Wong C, Law S. Extent of lymphadenectomy for Barrett’s cancer. Transl Gastroenterol Hepatol. 2019;4(36):1–7. (Epub 24/5/2019).CrossRefGoogle Scholar
  24. 24.
    Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, et al. Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg. 2004;240(6):962–72.CrossRefGoogle Scholar
  25. 25.
    Altorki N, Kent M, Ferrara C, Port J. Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg. 2002;236(2):177–83.CrossRefGoogle Scholar
  26. 26.
    Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg. 2007;246(6):992–1000. (Discussion-1. PubMed PMID: 18043101. Epub 2007/11/29).CrossRefPubMedGoogle Scholar
  27. 27.
    Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347(21):1662–9.CrossRefGoogle Scholar
  28. 28.
    Sasako M, Sano T, Yamamoto S, Sairenji M, Arai K, Kinoshita T, et al. Left thoracoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial. Lancet Oncol. 2006;7(8):644–51.CrossRefGoogle Scholar
  29. 29.
    Kurokawa Y, Sasako M, Sano T, Yoshikawa T, Iwasaki Y, Nashimoto A, et al. Ten-year follow-up results of a randomized clinical trial comparing left thoracoabdominal and abdominal transhiatal approaches to total gastrectomy for adenocarcinoma of the oesophagogastric junction or gastric cardia. Br J Surg. 2015;102(4):341–8. (PubMed PMID: 25605628; PubMed Central PMCID: PMCPMC5024022. Epub 2015/01/22).CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Haverkamp L, Seesing MFJ, Ruurda JP, Boone J, Hillegersberg RV. Worldwide trends in surgical techniques in the treatment of esophageal and gastroesophageal junction cancer. Dis Esophagus. 2017;30(1):1–7. Scholar

Copyright information

© The International Gastric Cancer Association and The Japanese Gastric Cancer Association 2019

Authors and Affiliations

  1. 1.Center for Esophageal and Gastric Cancer SurgeryAGAPLESION Markushospital FrankfurtFrankfurt am MainGermany
  2. 2.Contilia Center for Esophageal DiseasesElisabeth Hospital EssenEssenGermany
  3. 3.Department of Surgery, Queen Mary HospitalThe University of Hong KongHong Kong (SAR)China

Personalised recommendations