Gastroesophageal Junction Adenocarcinoma Siewert Type II and III - Surgical Management and Early Postoperative Outcomes. A Single-Center Retrospective Study

Background: Gastroesophageal cancer represents a challenging localisation in terms of operative management. The best long-term results is given by the complete resection of the tumour with an adequate lymphadenectomy which often requires the addition of a thoracic approach. Currently there is still debate regarding the surgical management of Siewert type II and III tumours. The aim of this study was to analyse the surgical approach in terms of morbidity and pathological results on a continuous series of patients, in a comparative manner.

Methods: We performed a retrospective analysis on a prospective collected database that included all the gastro-esophageal tumours from January 2015 and December 2025. We selected only the Siewert type II and III tumours. We presented the patients and tumour characteristics, the surgical approach, early postoperative complications and final pathological results.

Results: A total of 95 patients were included in the study, 40 patients (42.1%) presented Siewert type II tumours and 55 patients (57.9%) had Siewert type III adenocarcinomas with an overall mean age of 66.5 years (64.58-68.42). The Charlson comorbidity index showed no differences, overall mean index was 4.38(3.98-4.77), relatively similar in the two groups 4.4 (3.83-4.96) vs 4.44 (3.87-5.01), p=0.37. For patients with Siewert II tumours in 22 cases (55%) an approach only through a median laparotomy was chosen, a combined thoracoabdominal approach 12 cases (30%), median laparotomy and left thoracotomy [6 cases (15%)]. There were 8 patients (8.4%) that developed esojejunal fistula, 3 cases (7.5%) for Siewert II tumours and 5 cases (9.1%) for type III tumours. One of the most common surgical complications was surgical site infection in 20 patients (21%), more frequent in patients with Siewert type II tumours, 12 cases (30%) vs. 8 cases (14.5%), p=0.06, more frequent in patients in which a thoracotomy was required. Overall grade III and above medical complications were encountered in 30 cases (31.5%), the most common were pulmonary infectious complications, more frequent in patients with Siewert II tumours [14 cases (35%) vs 6 cases (10.9%), p=0.004]. Complete pathological response was obtained in 6 cases (6.3%), more common for Siewert II tumours [5 cases (12.5%) vs. 1 case (1.8%), p=0.03]. Patients had a similar stage distribution in the two groups, the most common was stage III [50 cases (52.6%)] and more frequent had poorly differentiated tumours [45 cases (47.4%)] with microscopic lymphatic invasion (71.6%) and vascular invasion (51.6%).

Conclusion: Any attempt should be made to obtain complete surgical resection. In this cohort, no statistically significant increase in overall complications was observed among patients undergoing thoracotomy. However, this finding should be interpreted with caution and should not be considered evidence that thoracotomy carries no additional risk.

Keywords: gastroesophageal cancer, Siewert classification, thoracotomy, morbidity

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