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Moderne Diagnostik und stadiengerechte Chirurgie

Therapie des Adenokarzinoms des ösophagogastralen Übergangs

Modern diagnostics and stage-oriented surgery

Therapy of adenocarcinoma of the esophagogastric junction

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Zusammenfassung

Basis der Entscheidungsfindung für die individualisierte chirurgische Therapie des Adenokarzinoms des ösophagogastralen Übergangs (AEG) ist das Tumorstaging und die exakte topographische Zuordnung des Tumors am anatomisch schmalen Übergang zwischen Ösophagus und Magen. Die Hauptsäulen der Diagnostik bestehen aus Endoskopie, Biopsie, Endosonographie, Computertomographie und eventuell diagnostischer Laparoskopie. Daraus resultiert ein klinisches TNM-Stadium und eine Bewertung nach der AEG-Klassifikation, welche die Tumoren von oral nach aboral in Typ I (Ösophagus), II (Kardia) und III (Subkardia) unterteilt.

Nur die seltenen Mukosakarzinome können unter strengen Voraussetzungen endoskopisch abgetragen werden; die Chirurgie steht in der überwiegenden Anzahl der Karzinome weiterhin im Mittelpunkt der Behandlung. Sie ist heute eingebettet in ein multimodales Behandlungskonzept, welches bei T3- und resektablen T4-Karzinomen der radikalen Resektion eine neoadjuvante Therapie voranstellt.

Bei Typ-I-Karzinomen erfolgt eine transthorakale En-bloc-Ösophagektomie mit hoch intrathorakaler Anastomose nach Magenhochzug. Bei Typ II oder III wird eine transhiatal erweiterte Gastrektomie mit distaler Ösophagusresektion und Rekonstruktion nach Roux-Y mit Ösophagojejunostomie durchgeführt. Manche fortgeschrittenen Typ-II-Karzinome die transhiatal am Ösophagus nicht sicher R0-reseziert werden können, erfordern jedoch eine Ösophagektomie. Diese chirurgische Strategie liegt in der Höhenlokalisation des Tumors und dem davon abhängigen Lymphabstrom begründet.

Für lokal limitierte Resektionen mit Dünndarminterposition oder die totale Ösophagogastrektomie mit Rekonstruktion durch Koloninterponat bestehen nur selten Indikationen.

Die neoadjuvante Radiochemotherapie bietet bei lokal fortgeschrittenen AEG-Typ-I-Karzinomen, die neoadjuvante Chemotherapie bei lokal fortgeschrittenen AEG-Typ-II- und -III-Karzinomen signifikante Überlebensvorteile im Vergleich zur alleinigen Operation.

Abstract

The basis for decision-making about an individualized surgical treatment of adenocarcinoma of the esophagogastric junction is tumor staging and exact evaluation of the topography of the tumor in the small junctional area.

The diagnostics mainly comprise endoscopy, biopsy, endosonography, computed tomography and partially diagnostic laparoscopy. This results in a clinical TNM staging and an evaluation according to the AEG classification from oral to aboral in type I (esophagus), type II (cardia) and type III (subcardia).

Endoscopic resection is only appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. This is combined with neoadjuvant treatment in case of T3 or resectable T4 carcinomas.

A type I carcinoma is removed by radical transthoracic en bloc esophagectomy with high intrathoracic esophagogastrostomy after gastric pull-up. In case of type II or III carcinomas, a transhiatal extended gastrectomy including distal esophageal resection is performed with reconstruction by Roux en Y esophagojejunostomy in the lower mediastinum. However, some advanced type II carcinomas which cannot be resected R0 at the esophagus need esophagectomy and gastric pull-up. This surgical strategy is justified by the topography of the lesion and the corresponding lymphatic drainage.

Very rare indications are seen for a limited resection with interposition of small bowel in some mucosal carcinomas or total esophagogastrectomy with colon interposition in very advanced tumors.

The neoadjuvant treatment comprises especially chemoradiation for type I and chemotherapy for type II and III carcinomas and leads to a significant survival benefit compared to surgery alone.

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  1. Klinik und Poliklinik für Allgemein-, Viszeral- und Tumorchirurgie, Universität Köln, Kerpener-Str. 62, 50937, Köln, Deutschland

    A.H. Hölscher & U.K. Fetzner

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  2. U.K. Fetzner
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Correspondence to A.H. Hölscher.

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Hölscher, A., Fetzner, U. Moderne Diagnostik und stadiengerechte Chirurgie. Chirurg 83, 702–711 (2012). https://doi.org/10.1007/s00104-011-2264-8

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