Oesophagogastric Junction Cancer

Oesophagogastric junction cancer arises around the anatomical transition between distal oesophagus and proximal stomach. Most are adenocarcinomas.

The Siewert classification remains useful for surgical planning:

Type I: tumour centre 1 to 5 cm above the junction
Type II: tumour centre from 1 cm above to 2 cm below the junction
Type III: tumour centre 2 to 5 cm below the junction

Type I behaves predominantly as distal oesophageal cancer. Type III behaves predominantly as proximal gastric cancer. Type II lies between these patterns and requires careful assessment of proximal and distal extension and lymphatic drainage.

Upper gastrointestinal endoscopy with biopsy: establish histology and accurately document the tumour centre relative to the junction.

CT chest, abdomen and pelvis plus PET CT where appropriate: establish metastatic disease and resectability.

Endoscopic ultrasound: defines local depth and regional nodes when potentially curative treatment is planned.

Staging laparoscopy with peritoneal washings is particularly important when the tumour has a substantial gastric component, advanced T stage, nodal disease or poorly cohesive histology because small volume peritoneal disease can be missed on conventional imaging.

Treatment requires both appropriate systemic therapy and an operation that provides an R0 resection with adequate lymphadenectomy.

Perioperative therapy

For resectable gastric and gastroesophageal junction adenocarcinoma, durvalumab plus FLOT is now an approved perioperative option and produced better event free survival than FLOT alone.

FLOT every 14 days:

Docetaxel 50 mg/m² IV
Oxaliplatin 85 mg/m² IV
Leucovorin 200 mg/m² IV
Fluorouracil 2600 mg/m² continuous infusion over 24 hours

Four FLOT treatments are given before surgery and four after surgery.

For patients weighing at least 30 kg:

Durvalumab 1500 mg IV every 4 weeks with perioperative chemotherapy for up to four durvalumab cycles, followed by durvalumab 1500 mg IV every 4 weeks for up to ten additional cycles.

Availability and regulatory approval vary by country.

FLOT without immunotherapy remains a valid perioperative regimen where durvalumab is unavailable or inappropriate.

Surgery

Siewert I: usually treated with transthoracic oesophagectomy and mediastinal plus upper abdominal lymphadenectomy.

Siewert III: generally treated as gastric cancer with total gastrectomy, distal oesophageal resection and appropriate perigastric lymphadenectomy.

Siewert II: the operation is individualised according to tumour extension. Transthoracic oesophagectomy is favoured when oesophageal involvement and mediastinal nodal risk dominate. Extended total gastrectomy with distal oesophagectomy may be appropriate when disease is predominantly gastric and an adequate proximal margin can be achieved.

The objective is anatomical, not semantic: achieve an R0 resection while removing the lymphatic basin at greatest risk.

Metastatic or unresectable disease requires biomarker directed systemic therapy. Test adenocarcinoma for HER2, PD L1, MSI or mismatch repair deficiency and relevant additional targets.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Gastric Fistula

A gastric fistula is an abnormal communication between the gastric lumen and another epithelial surface or organ.

It may communicate with:

Skin, producing a gastrocutaneous fistula
Colon, producing a gastrocolic fistula
Small bowel
Pleural or thoracic cavity
Another portion of the stomach

Most clinically important postoperative fistulas evolve from a gastric staple line, anastomotic or perforation leak that fails to heal and becomes a chronic epithelialised tract.

Common settings include sleeve gastrectomy, gastrectomy, gastrojejunostomy, oesophagogastric surgery, trauma, malignancy and chronic peptic disease.

A leak is an acute transmural defect. A fistula is usually a more mature pathological communication between epithelialised surfaces.

Acute postoperative leakage may present before a mature fistula forms.

Important features include:

Persistent tachycardia
Fever
Left upper abdominal or shoulder pain
Sepsis
Purulent or gastric drain output
Enteric material from the wound
Failure to tolerate oral intake

A chronic gastrocutaneous fistula may present with persistent acidic gastric drainage through the abdominal wall, causing severe skin excoriation and fluid loss.

A gastrocolic fistula can produce diarrhoea, weight loss, malnutrition, foul eructation or faeculent vomiting.

Persistent tachycardia after upper gastrointestinal surgery should never be dismissed simply because abdominal examination is mild.

CT abdomen with oral and IV contrast: define the fistula or leak, associated collection and whether there is distal obstruction.

Upper gastrointestinal endoscopy: defines the internal opening and allows therapeutic intervention.

A contrast study may help delineate anatomy in a chronic external fistula.

Assess full blood count, renal function, electrolytes, magnesium, phosphate and nutritional status. Measure external fistula output daily.

The most important diagnostic questions are:

Is there uncontrolled sepsis?
Is there a drainable collection?
Is there distal obstruction?
Is the defect acute or chronic?
Is surrounding tissue viable?

These determine whether closure is likely to succeed.

Management begins with source control and physiological recovery, not immediate closure of the fistula.

Sepsis and collections

Keep fasting initially when an uncontrolled acute leak is present.

Drain associated collections percutaneously, endoscopically or surgically according to anatomy.

For significant postoperative gastric sepsis:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Use culture results to narrow therapy.

Prolonged antibiotics are not a substitute for drainage.

Give acid suppression, for example:

Pantoprazole 40 mg IV or orally every 12 hours during active high output gastric leakage.

Nutrition

Nutrition is central to fistula healing.

Use enteral feeding distal to the fistula whenever feasible, such as nasojejunal or feeding jejunostomy nutrition.

Use parenteral nutrition when enteral feeding cannot adequately meet requirements or markedly increases fistula output.

Correct magnesium, phosphate, potassium and micronutrient deficiencies aggressively.

Protect surrounding skin from acidic gastric effluent.

Endoscopic treatment

Endoscopic therapy has become central to postoperative gastric leaks and fistulas. Choice depends on defect size, chronicity, associated cavity and tissue quality.

Clips: best for small fresh defects with healthy pliable margins.

An over the scope clip provides stronger full thickness closure than standard clips and is useful for selected small fistula openings.

Endoscopic suturing: useful for larger defects when tissue can be approximated without excessive tension.

Fully covered self expanding stent: diverts luminal contents across selected acute leaks, particularly proximal gastric and oesophagogastric defects.

Stent migration is a major limitation.

Endoscopic internal drainage: useful when a contained perigastric cavity can be drained internally into the gastric lumen.

Endoscopic vacuum therapy: particularly effective for leaks associated with infected cavities. A sponge or vacuum device is positioned within the defect or cavity and exchanged serially, promoting drainage and granulation.

Chronic epithelialised fistulas are harder to close than fresh leaks because the tract has matured. De epithelialisation or tract preparation may be required before clipping or suturing.

Surgery

Operate when there is:

Generalised peritonitis
Haemodynamic instability
Uncontrolled sepsis despite drainage
Gastric necrosis
Large uncontained disruption
Distal mechanical obstruction preventing healing
Failed appropriate endoscopic therapy
Chronic fistula with anatomy unsuitable for minimally invasive closure

Definitive surgery may require fistula tract excision, gastric resection, revision of the original anastomosis or reconstruction.

Do not perform repeated closure attempts without correcting distal obstruction, uncontrolled infection or severe malnutrition. These are major reasons fistulas fail to heal.

Oesophagogastric Junction Cancer

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management