Authors: Li Shuangxi, Li Ziyu, Ji Jiafu
Source: Chinese Journal of Gastrointestinal Surgery, 2023, 26(8)
summary
objective
To understand the clinical diagnosis and treatment concept of esophagogastric junction adenocarcinoma (AEG) by the Chinese gastric surgeon group [Chinese Laparoscopic Gastrointestinal Surgery Research Group (CLASS)-10 study]. MethodsThe questionnaires were distributed in the WeChat group of the CLASS-10 research group (including researchers and research assistants from 32 centers in China, all of whom were gastric surgeons), and the surveys were conducted before the start of the study (2020) and in the middle of the study (2022). The survey was mainly based on AEG's concept of surgical diagnosis and treatment, which mainly included three aspects: diagnosis, surgical treatment and perioperative management. In the second survey, on the basis of the first questionnaire, the survey content of the respondents' job titles, hospital types and AEG definitions was added. In the surgical treatment section, a supplementary investigation was conducted on the perspective of lower mediastinal lymph node dissection in the CLASS-10 study. The participants' clinical perception of AEG was recorded, and the differences in the diagnosis and treatment concept between the two surveys were analyzed. ResultsA total of 32 and 34 questionnaires were collected from the two surveys, respectively. Regarding the definition of AEG, the Chinese expert consensus has the highest acceptance (18/34, 52.9%), that is, adenocarcinoma with a tumor center within 5 cm above and below the esophagogastric junction (EGJ) and crossing or touching the esophagogastric junction. Regarding the basis for judging EGJ before surgery, the proportion of dentate lines increased from 68.8% (22/32) to 88.2% (30/34), and the difference was not statistically significant (P=0.143). For the determination of AEG length diameter and center point, the proportion of gastroscopy increased from 53.1% (17/32) to 73.5% (25/34), and the difference was statistically significant (P=0.040). For the judgment of postoperative specimen EGJ, the proportion of dentate lines increased from 59.4% (19/32) to 85.3% (29/34), and the difference was statistically significant (P=0.027). In 2022, 82.4% (28/34) of the respondents said they were proficient in lower mediastinal lymph node dissection. For the safe proximal margin distance of AEG surgery, the proportion of "≥1 cm, <2 cm" increased from 6.3% (2/32) to 26.5% (9/34), but the difference was not statistically significant (P=0.158). For the method of determining the proximal resection margin of AEG without serous layer invasion, the proportion of "intraoperative palpation" increased from 3.1% (1/32) to 23.5% (8/34), and the proportion of "intraoperative gastroscopy" decreased from 62.5% (20/32) to 35.3% (12/34), and the difference was statistically significant (P=0.018). ConclusionsIn the CLASS10 study group, AEG China has a high acceptance of the expert consensus definition. For the diagnosis of AEG, the proportion of gastroscopy and dentate line recognition tends to increase. For surgical treatment of AEG, there is a trend towards a decrease in the distance between safe proximal margins. Worldwide, the incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing year by year, and it has become a research hotspot in the field of gastric cancer surgery. However, there is still a lack of high-level evidence-based evidence for the surgical treatment of AEG. There is no consensus on the definition of AEG, surgical approach, scope of resection, and scope of lymph node dissection. For example, the definition of AEG is not unified, and there are currently Siewert classifications, Nishi classifications, and expert consensus definitions proposed by the mainland. There is also controversy about the indications for lower mediastinal lymph node dissection, and the 5th edition of the Japanese guidelines for the treatment of gastric cancer recommends dissection for tumors of type E, EG, and E=G, but in the 6th edition of the guidelines, it is recommended to recommend the > distance of esophageal invasion2 cm. To this end, Peking University Cancer Hospital conducted a phase II.b study based on the IDEAL framework for locally advanced AEG (Siewert type II, III.) to explore the clinical efficacy of laparoscopic mediastinal lymph node dissection, namely the Chinese Laparoscopic Gastrointestinal Surgery Study Group (CLASS)-10 study. In the study design stage (2020), we developed relevant questionnaires to understand the clinical diagnosis and treatment of AEG in the participating centers, improve study compliance and estimate the speed of enrollment. In the middle of the study (2022), we conducted a second survey to understand the changes in the participating centers' perceptions of AEG diagnosis and treatment. This article summarizes and analyzes the results of these two current surveys, in order to show the research concepts and changes of domestic gastric surgeons on AEG surgical diagnosis and treatment in recent years, and to provide reference for domestic clinicians to carry out related research in the future.
Information and Methodology
1. Survey Respondents
A questionnaire survey was conducted using the research method of the current situation survey.
The questionnaire was distributed to the CLASS-10 investigators' WeChat group, which was composed of researchers and research assistants from 32 centers in China, and the participants were all gastric surgeons.
Second, the content of the investigation
The survey was conducted on January 3, 2020 and September 8, 2022. Both cases were conducted anonymously, and respondents were selected based on their understanding of AEG's clinical diagnosis and treatment concept. The survey was mainly based on AEG's concept of surgical diagnosis and treatment, which mainly included three aspects: diagnosis, surgical treatment and perioperative management. In the second survey, on the basis of the first questionnaire, the survey content of the respondents' job titles, hospital types and AEG definitions was added. In the surgical treatment section, a supplementary investigation was conducted on the perspective of lower mediastinal lymph node dissection in the CLASS-10 study.
3. Questionnaire distribution and collection
Compile the survey content on the Questionnaire Star platform and generate a link to the survey. Respondents access the survey content through a link, each IP address is limited to one answer, there is no time limit for answering, each question is mandatory, and the options that have been answered can be changed before the questionnaire is submitted. The questionnaire was closed and collected within 72 hours after distribution.
4. Statistical Methods
STATA 15.0 software was used for statistical analysis. Counting data are described in the form of people (%). Since the two surveys were conducted anonymously and could not be matched, the categorical variables in the two surveys were compared using the Fisher exact probability test. Because the number of selected options is 0 or the theoretical frequency is <1, some options are combined when comparing some of the survey items. The Mann-Whitney U test was used for comparison of grade data. P<0.05 indicated that the difference was statistically significant.
outcome
1. Respondents
A total of 32 and 34 questionnaires were collected in the two surveys, with recovery rates of 64.0% and 57.6%, respectively. The IP addresses and geographical locations of the respondents in the two surveys are shown in Table 1.
2. Definition of AEG
The most accepted was the definition of Chinese expert consensus (18 people, 52.9%). Among the diagnostic elements of AEG, 22 people (64.7%) believed that tumor contact or invasion of the esophagogastric junction (EGJ) was the most important.
3. Diagnosis and identification of AEG
In both surveys, gastroscopy was considered the most important diagnostic method, and the proportion of gastroscopy increased in 2022 compared to 2020. In terms of judging the length diameter and center point of AEG, the proportion of gastroscopy increased from 53.1% to 73.5% (P=0.040). In terms of the judgment of EGJ invasion, the proportion of gastroscopy increased from 81.3% to 97.1% (P=0.051). In terms of the identification of EGJ specimens, the proportion of dentate lines as the identification marker increased from 59.4% to 85.3% (P=0.027). Dentate lines were still the most chosen anatomical landmarks in the preoperative identification of EGJ, with 68.8% and 88.2% of the two surveys, respectively. The lower esophageal palisade vessel (LEPV) and proximal end of gastric fold (PEGF), which are the "gold standard", were selected in 12.5% (4/32) and 5.9% (2/34), respectively, in the two surveys. See Table 2.
4. Surgical treatment of AEG
The two surveys showed that there was an increasing trend in the number of surgical procedures performed at AEG in 2022 compared to 2020, with an increase in the proportion of centers completing proximal gastrectomy > 20% [43.8% (14/32) vs. 52.9% (18/34)].
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Investigation and analysis of the current status of the clinical diagnosis and treatment of adenocarcinoma at the esophagogastric junction in the CLASS-10 research group
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