[Modern diagnostics and stage-oriented surgery: therapy of adenocarcinoma of the esophagogastric junction].

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.