Are There Any Problems with Siewert’s Classification for Cancer of the Cardia?
The optimal surgical approach for adenocarcinoma of the gastroesophageal junction has been controversial, even with the appearance of an anastomotic instrument. Recently, Siewert's classification of adenocarcinoma of the gastroesophageal junction has come into popular use for deciding on the operative procedure for carcinoma of the cardia. However, there are some unresolved problems regarding its practical use is not authorized with regard to the safety resection margin of the esophagus. The classification is made from the location of the tumor center and its concepts are based on the trend of the lymphatic spread of Type I, II and III tumors. However, the area of the lymph nodes which can be dissected in transhiatal blunt dissection and an extended total gastrectomy under division of the central tendon of the diaphragm does not differ. Selection of operative procedure should be based on the clearance from the neoplasm at the resection margin, if the tumor was resected curatively. Our indications for operative procedures for carcinoma of the cardia seem to be more legitimate than Siewert's classification because the decision is based on a precise analysis of skip lesions and residual tumors on the remaining esophagus. We would like to emphasize that a decsion regarding the resection line and operative procedure should be made before an operation, because it could be quite difficult to do so during the operation since ; (1) a skip lesion usually cannot be detected, (2) frozen section examination is unreliable for determining tumor clearance of the resection margin, and (3) the surgeon might wish to avoid changing the operative procedure to a more stressful one.