Precision surgical treatment strategies for advanced Siewert type Ⅱ adenocarcinoma of the esophagogastric junction_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

DENG Haowen ¹ , XIONG Wenjun ² , TANG Hongsheng ² , LIN Zeyu ¹ ,  WANG Wei ²

1. The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, P. R. China;
2. Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Clinical Research Academy of Chinese Medicine, Guangzhou 510405, P. R. China;

Corresponding?author：

WANG Wei, Email: wangwei16400@163.com

Keywords：

adenocarcinoma of the esophagogastric junction; Siewert type Ⅱ; advanced; surgical approach; lymphadenectomy; proximal esophageal resection margin; digestive tract reconstruction

DOI：

10.7507/1007-9424.202604148

Video：

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Abstract Full text Figures/Tables Video References Cited by

Advanced Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (AEG) has a unique anatomical location and exhibits heterogeneous biological behavior resembling both esophageal and gastric cancers. It is associated with a high risk of bidirectional lymphatic metastasis to the abdominal cavity and mediastinum, and is often diagnosed at a relatively advanced stage. Therefore, the establishment of precision surgical treatment strategies for this disease remains challenged by several key issues. Based on the latest clinical evidence, guidelines, and expert consensus from China and abroad, and combined with our institutional clinical experience, this article discusses the individualized selection of surgical approaches, precise definition of the extent of lymphadenectomy, safe threshold for the proximal esophageal resection margin, and strategies for digestive tract reconstruction.

Citation： DENG Haowen, XIONG Wenjun, TANG Hongsheng, LIN Zeyu, WANG Wei. Precision surgical treatment strategies for advanced Siewert type Ⅱ adenocarcinoma of the esophagogastric junction. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(5): 617-622. doi: 10.7507/1007-9424.202604148 Copy

1.	Siewert JR, H?lscher AH, Becker K, et al. Cardia cancer: attempt at a therapeutically relevant classification. Chirurg, 1987, 58(1): 25-32.
2.	Maric R, Cheng KK. Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg, 1999, 86(8): 1098-1099.
3.	中國醫師協會內鏡醫師分會腹腔鏡外科專業組, 國際食管疾病學會中國分會, 中國食管胃結合部腺癌研究協作組, 等. 食管胃結合部腺癌外科治療中國專家共識 (2024年版). 中華胃腸外科雜志, 2024, 27(2): 109-126.
4.	Brown AM, Giugliano DN, Berger AC, et al. Surgical approaches to adenocarcinoma of the gastroesophageal junction: the Siewert Ⅱ conundrum. Langenbecks Arch Surg, 2017, 402(8): 1153-1158.
5.	Parry K, Haverkamp L, Bruijnen RC, et al. Surgical treatment of adenocarcinomas of the gastro-esophageal junction. Ann Surg Oncol, 2015, 22(2): 597-603.
6.	Blank S, Schmidt T, Heger P, et al. Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG Ⅱ): thoracoabdominal or abdominal approach? Gastric Cancer, 2018, 21(2): 303-314.
7.	董家鴻, 張寧. 精準外科. 中華外科雜志, 2015, 53(5): 321-323.
8.	中華醫學會外科學分會腹腔鏡與內鏡外科學組, 中國醫師協會外科醫師分會上消化道外科醫師專家工作組, 《中華消化外科雜志》編輯委員會. 精準胃癌外科診療中國專家共識 (2024版). 中華消化外科雜志, 2024, 23(3): 323-333.
9.	Kamarajah SK, Phillips AW, Griffiths EA, et al. Esophagectomy or total gastrectomy for Siewert 2 gastroesophageal junction (GEJ) adenocarcinoma? A registry-based analysis. Ann Surg Oncol, 2021, 28(13): 8485-8494.
10.	Omloo JM, Lagarde SM, Hulscher JB, 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.
11.	Sasako M, Sano T, Yamamoto S, 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): 644-651.
12.	Kurokawa Y, Sasako M, Sano T, 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): 341-348.
13.	Huang C, Liu H, Hu Y, et al. Laparoscopic vs open distal gastrectomy for locally advanced gastric cancer: five-year outcomes from the CLASS-01 randomized clinical trial. JAMA Surg, 2022, 157(1): 9-17.
14.	Son SY, Hur H, Hyung WJ, et al. Laparoscopic vs open distal gastrectomy for locally advanced gastric cancer: 5-year outcomes of the KLASS-02 randomized clinical trial. JAMA Surg, 2022, 157(10): 879-886.
15.	Katai H, Mizusawa J, Katayama H, et al. Survival outcomes after laparoscopy-assisted distal gastrectomy versus open distal gastrectomy with nodal dissection for clinical stage IA or IB gastric cancer (JCOG0912): a multicentre, non-inferiority, phase 3 randomised controlled trial. Lancet Gastroenterol Hepatol, 2020, 5(2): 142-151.
16.	Chen XD, He FQ, Liao MS, et al. Laparoscopic versus open transhiatal approach for adenocarcinoma of the esophagogastric junction: a systematic review and meta-analysis. Eur J Surg Oncol, 2021, 47(4): 778-788.
17.	Huang CM, Lv CB, Lin JX, et al. Laparoscopic-assisted versus open total gastrectomy for Siewert type Ⅱ and Ⅲ esophagogastric junction carcinoma: a propensity score-matched case-control study. Surg Endosc, 2017, 31(9): 3495-3503.
18.	Bras Harriott C, Angeramo CA, Casas MA, et al. Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: systematic review and meta-analysis. J Thorac Cardiovasc Surg, 2022, 164(6): e233-e254.
19.	Casas MA, Angeramo CA, Bras Harriott C, et al. Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis. Eur J Surg Oncol, 2022, 48(3): 473-481.
20.	中華醫學會外科學分會腹腔鏡與內鏡外科學組. Siewert Ⅱ型食管胃結合部腺癌腔鏡手術治療中國專家共識(2023版). 中華消化外科雜志, 2023, 22(7): 799-809.
21.	中國抗癌協會腫瘤胃病學專業委員會. 腹腔鏡經腹膈肌入路Siewert Ⅱ型食管胃結合部腺癌手術操作標準 (2024版). 中華胃腸外科雜志, 2024, 27(11): 1093-1099.
22.	Li J, Xiong W, Ou H, et al. Transthoracic single-port-assisted laparoscopic gastrectomy versus laparoscopic transhiatal approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a single-center retrospective study. Surg Endosc, 2024, 38(4): 1986-1994.
23.	Xiong W, Chen Y, Zhu X, et al. Transthoracic single-port assisted laparoscopic five-step maneuver lower mediastinal lymphadenectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction. Ann Surg Oncol, 2022, 29(6): 3936-3937.
24.	Xiong W, Zhong X, Chen Y, et al. A novel surgical technique for dissection of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: the transthoracic single-port assisted laparoscopic esophagogastrostomy. Gastroenterol Rep (Oxf), 2022, 10: goab057. doi: 10.1093/gastro/goab057.
25.	Kurokawa Y, Takeuchi H, Doki Y, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study. Ann Surg, 2021, 274(1): 120-127.
26.	Zheng J, Li Y, Fan L, et al. Prospective evaluation of radical surgery for adenocarcinoma of oesophagogastric junction: real-world insights from the CLAEG study. Gut, 2026: gutjnl-2025-337393. doi: 10.1136/gutjnl-2025-337393.
27.	Kurokawa Y, Takeuchi H, Doki Y, et al. Establishing a standard surgery for esophagogastric junction cancer: final results from the JGCA-JES nationwide prospective study. Cell Rep Med, 2026, 7(2): 102627. doi: 10.1016/j.xcrm.2026.102627.
28.	Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2025 (7th edition). Gastric Cancer, 2026, 29(2): 271-299.
29.	Barbour AP, Rizk NP, Gonen M, et al. Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome. Ann Surg, 2007, 246(1): 1-8.
30.	Mine S, Sano T, Hiki N, 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): 1050-1054.
31.	Shin Y, Yamamoto M, Ota M, et al. Appropriate proximal resection margin distance for esophagogastric junction adenocarcinoma. Ann Surg Oncol, 2026, 33(5): 4232-4241.
32.	Shen JG, Cheong JH, Hyung WJ, et al. Intraoperative frozen section margin evaluation in gastric cancer of the cardia surgery. Hepatogastroenterology, 2006, 53(72): 976-978.
33.	Shiraishi N, Hirose R, Morimoto A, et al. Gastric tube reconstruction prevented esophageal reflux after proximal gastrectomy. Gastric Cancer, 1998, 1(1): 78-79.
34.	Yamashita Y, Yamamoto A, Tamamori Y, et al. Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy. Gastric Cancer, 2017, 20(4): 728-735.
35.	Yamashita Y, Tatsubayashi T, Okumura K, et al. Modified side overlap esophagogastrostomy after laparoscopic proximal gastrectomy. Ann Gastroenterol Surg, 2022, 6(4): 594-599.
36.	Kuroda S, Choda Y, Otsuka S, et al. Multicenter retrospective study to evaluate the efficacy and safety of the double-flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD-FLAP Study). Ann Gastroenterol Surg, 2018, 3(1): 96-103.
37.	Peng W, Yan S, Huang Y, et al. Laparoscopic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (ROSF): a case-series study. BMC Surg, 2023, 23(1): 90. doi: 10.1186/s12893-023-01975-y.
38.	王偉東, 衛江鵬, 高瑞祺, 等. 腹腔鏡下近端胃切除食管胃吻合單肌瓣成形術初步體會. 中華胃腸外科雜志, 2022, 25(5): 462-465.
39.	李子禹, 王胤奎, 李百隆, 等. 近端胃切除術后食管殘胃“拱橋式”重建3例效果分析. 中華外科雜志, 2022, 60(3): 261-264.
40.	Kameyama J, Ishida H, Yasaku Y, et al. Proximal gastrectomy reconstructed by interposition of a jejunal pouch. Surgical technique. Eur J Surg, 1993, 159(9): 491-483.
41.	Aikou T, Natsugoe S, Shimazu H, et al. Antrum preserving double tract method for reconstruction following proximal gastrectomy. Jpn J Surg, 1988, 18(1): 114-115.
42.	Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil) after laparoscopic total gastrectomy. Surg Endosc, 2009, 23(11): 2624-2630.
43.	Omori T, Oyama T, Mizutani S, et al. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg, 2009, 197(1): e13-e17.
44.	Kim HI, Cho I, Jang DS, et al. Intracorporeal esophagojejunostomy using a circular stapler with a new purse-string suture technique during laparoscopic total gastrectomy. J Am Coll Surg, 2013, 216(2): e11-e16.
45.	Inaba K, Satoh S, Ishida Y, et al. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg, 2010, 211(6): e25-e29.
46.	Kwon IG, Son YG, Ryu SW. Novel intracorporeal esophagojejunostomy using linear staplers during laparoscopic total gastrectomy: π-shaped esophagojejunostomy, 3-in-1 technique. J Am Coll Surg, 2016, 223(3): e25-e29.

1. Siewert JR, H?lscher AH, Becker K, et al. Cardia cancer: attempt at a therapeutically relevant classification. Chirurg, 1987, 58(1): 25-32.
2. Maric R, Cheng KK. Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg, 1999, 86(8): 1098-1099.
3. 中國醫師協會內鏡醫師分會腹腔鏡外科專業組, 國際食管疾病學會中國分會, 中國食管胃結合部腺癌研究協作組, 等. 食管胃結合部腺癌外科治療中國專家共識 (2024年版). 中華胃腸外科雜志, 2024, 27(2): 109-126.
4. Brown AM, Giugliano DN, Berger AC, et al. Surgical approaches to adenocarcinoma of the gastroesophageal junction: the Siewert Ⅱ conundrum. Langenbecks Arch Surg, 2017, 402(8): 1153-1158.
5. Parry K, Haverkamp L, Bruijnen RC, et al. Surgical treatment of adenocarcinomas of the gastro-esophageal junction. Ann Surg Oncol, 2015, 22(2): 597-603.
6. Blank S, Schmidt T, Heger P, et al. Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG Ⅱ): thoracoabdominal or abdominal approach? Gastric Cancer, 2018, 21(2): 303-314.
7. 董家鴻, 張寧. 精準外科. 中華外科雜志, 2015, 53(5): 321-323.
8. 中華醫學會外科學分會腹腔鏡與內鏡外科學組, 中國醫師協會外科醫師分會上消化道外科醫師專家工作組, 《中華消化外科雜志》編輯委員會. 精準胃癌外科診療中國專家共識 (2024版). 中華消化外科雜志, 2024, 23(3): 323-333.
9. Kamarajah SK, Phillips AW, Griffiths EA, et al. Esophagectomy or total gastrectomy for Siewert 2 gastroesophageal junction (GEJ) adenocarcinoma? A registry-based analysis. Ann Surg Oncol, 2021, 28(13): 8485-8494.
10. Omloo JM, Lagarde SM, Hulscher JB, 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.
11. Sasako M, Sano T, Yamamoto S, 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): 644-651.
12. Kurokawa Y, Sasako M, Sano T, 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): 341-348.
13. Huang C, Liu H, Hu Y, et al. Laparoscopic vs open distal gastrectomy for locally advanced gastric cancer: five-year outcomes from the CLASS-01 randomized clinical trial. JAMA Surg, 2022, 157(1): 9-17.
14. Son SY, Hur H, Hyung WJ, et al. Laparoscopic vs open distal gastrectomy for locally advanced gastric cancer: 5-year outcomes of the KLASS-02 randomized clinical trial. JAMA Surg, 2022, 157(10): 879-886.
15. Katai H, Mizusawa J, Katayama H, et al. Survival outcomes after laparoscopy-assisted distal gastrectomy versus open distal gastrectomy with nodal dissection for clinical stage IA or IB gastric cancer (JCOG0912): a multicentre, non-inferiority, phase 3 randomised controlled trial. Lancet Gastroenterol Hepatol, 2020, 5(2): 142-151.
16. Chen XD, He FQ, Liao MS, et al. Laparoscopic versus open transhiatal approach for adenocarcinoma of the esophagogastric junction: a systematic review and meta-analysis. Eur J Surg Oncol, 2021, 47(4): 778-788.
17. Huang CM, Lv CB, Lin JX, et al. Laparoscopic-assisted versus open total gastrectomy for Siewert type Ⅱ and Ⅲ esophagogastric junction carcinoma: a propensity score-matched case-control study. Surg Endosc, 2017, 31(9): 3495-3503.
18. Bras Harriott C, Angeramo CA, Casas MA, et al. Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: systematic review and meta-analysis. J Thorac Cardiovasc Surg, 2022, 164(6): e233-e254.
19. Casas MA, Angeramo CA, Bras Harriott C, et al. Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis. Eur J Surg Oncol, 2022, 48(3): 473-481.
20. 中華醫學會外科學分會腹腔鏡與內鏡外科學組. Siewert Ⅱ型食管胃結合部腺癌腔鏡手術治療中國專家共識(2023版). 中華消化外科雜志, 2023, 22(7): 799-809.
21. 中國抗癌協會腫瘤胃病學專業委員會. 腹腔鏡經腹膈肌入路Siewert Ⅱ型食管胃結合部腺癌手術操作標準 (2024版). 中華胃腸外科雜志, 2024, 27(11): 1093-1099.
22. Li J, Xiong W, Ou H, et al. Transthoracic single-port-assisted laparoscopic gastrectomy versus laparoscopic transhiatal approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a single-center retrospective study. Surg Endosc, 2024, 38(4): 1986-1994.
23. Xiong W, Chen Y, Zhu X, et al. Transthoracic single-port assisted laparoscopic five-step maneuver lower mediastinal lymphadenectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction. Ann Surg Oncol, 2022, 29(6): 3936-3937.
24. Xiong W, Zhong X, Chen Y, et al. A novel surgical technique for dissection of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: the transthoracic single-port assisted laparoscopic esophagogastrostomy. Gastroenterol Rep (Oxf), 2022, 10: goab057. doi: 10.1093/gastro/goab057.
25. Kurokawa Y, Takeuchi H, Doki Y, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study. Ann Surg, 2021, 274(1): 120-127.
26. Zheng J, Li Y, Fan L, et al. Prospective evaluation of radical surgery for adenocarcinoma of oesophagogastric junction: real-world insights from the CLAEG study. Gut, 2026: gutjnl-2025-337393. doi: 10.1136/gutjnl-2025-337393.
27. Kurokawa Y, Takeuchi H, Doki Y, et al. Establishing a standard surgery for esophagogastric junction cancer: final results from the JGCA-JES nationwide prospective study. Cell Rep Med, 2026, 7(2): 102627. doi: 10.1016/j.xcrm.2026.102627.
28. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2025 (7th edition). Gastric Cancer, 2026, 29(2): 271-299.
29. Barbour AP, Rizk NP, Gonen M, et al. Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome. Ann Surg, 2007, 246(1): 1-8.
30. Mine S, Sano T, Hiki N, 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): 1050-1054.
31. Shin Y, Yamamoto M, Ota M, et al. Appropriate proximal resection margin distance for esophagogastric junction adenocarcinoma. Ann Surg Oncol, 2026, 33(5): 4232-4241.
32. Shen JG, Cheong JH, Hyung WJ, et al. Intraoperative frozen section margin evaluation in gastric cancer of the cardia surgery. Hepatogastroenterology, 2006, 53(72): 976-978.
33. Shiraishi N, Hirose R, Morimoto A, et al. Gastric tube reconstruction prevented esophageal reflux after proximal gastrectomy. Gastric Cancer, 1998, 1(1): 78-79.
34. Yamashita Y, Yamamoto A, Tamamori Y, et al. Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy. Gastric Cancer, 2017, 20(4): 728-735.
35. Yamashita Y, Tatsubayashi T, Okumura K, et al. Modified side overlap esophagogastrostomy after laparoscopic proximal gastrectomy. Ann Gastroenterol Surg, 2022, 6(4): 594-599.
36. Kuroda S, Choda Y, Otsuka S, et al. Multicenter retrospective study to evaluate the efficacy and safety of the double-flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD-FLAP Study). Ann Gastroenterol Surg, 2018, 3(1): 96-103.
37. Peng W, Yan S, Huang Y, et al. Laparoscopic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (ROSF): a case-series study. BMC Surg, 2023, 23(1): 90. doi: 10.1186/s12893-023-01975-y.
38. 王偉東, 衛江鵬, 高瑞祺, 等. 腹腔鏡下近端胃切除食管胃吻合單肌瓣成形術初步體會. 中華胃腸外科雜志, 2022, 25(5): 462-465.
39. 李子禹, 王胤奎, 李百隆, 等. 近端胃切除術后食管殘胃“拱橋式”重建3例效果分析. 中華外科雜志, 2022, 60(3): 261-264.
40. Kameyama J, Ishida H, Yasaku Y, et al. Proximal gastrectomy reconstructed by interposition of a jejunal pouch. Surgical technique. Eur J Surg, 1993, 159(9): 491-483.
41. Aikou T, Natsugoe S, Shimazu H, et al. Antrum preserving double tract method for reconstruction following proximal gastrectomy. Jpn J Surg, 1988, 18(1): 114-115.
42. Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil) after laparoscopic total gastrectomy. Surg Endosc, 2009, 23(11): 2624-2630.
43. Omori T, Oyama T, Mizutani S, et al. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg, 2009, 197(1): e13-e17.
44. Kim HI, Cho I, Jang DS, et al. Intracorporeal esophagojejunostomy using a circular stapler with a new purse-string suture technique during laparoscopic total gastrectomy. J Am Coll Surg, 2013, 216(2): e11-e16.
45. Inaba K, Satoh S, Ishida Y, et al. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg, 2010, 211(6): e25-e29.
46. Kwon IG, Son YG, Ryu SW. Novel intracorporeal esophagojejunostomy using linear staplers during laparoscopic total gastrectomy: π-shaped esophagojejunostomy, 3-in-1 technique. J Am Coll Surg, 2016, 223(3): e25-e29.

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Precision surgical treatment strategies for advanced Siewert type Ⅱ adenocarcinoma of the esophagogastric junction

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