Esophagectomy versus Total Gastrectomy for Siewert Type II Esophagogastric Junction Adenocarcinoma: A Retrospective Cohort Study

Esophagectomy versus Total Gastrectomy for Siewert Type II Esophagogastric Junction Adenocarcinoma: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Esophagectomy versus Total Gastrectomy for Siewert Type II Esophagogastric Junction Adenocarcinoma: A Retrospective Cohort Study Muhammed Salih Süer, Nezih Akkapulu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4530102/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The incidence of gastric adenocarcinoma is declining, while cases located in the proximal stomach are increasing. Surgery remains the primary curative treatment option for gastric cancer. Debate persists regarding the optimal surgical approach for Siewert type II esophagogastric junction adenocarcinoma. This study aims to assess the outcomes of these surgical options based on real-world data, evaluating overall survival, mortality, anastomosis failure and complication rates. Methods: Between 2001 and 2021, 1015 patients underwent esophagectomy and total gastrectomy. After exclusions, 139 patients with Siewert type II adenocarcinoma were included. Results: Among 139 patients, the median age was 61.58 years, with a predominance of males. Total gastrectomy had a shorter hospital stay (p<0.01) and lower rates of anastomosis failure (p<0.001) and severe morbidity (p<0.05) compared to esophagectomy. Mortality rates at 30 and 90 days did not differ between the two groups. Tumor size was larger in the gastrectomy group (p<0.05). Locally advanced disease was predominant (89.2%). Overall five-year survival was 38.7%, with no significant difference between surgical approaches (p=0.891). Conclusion: This study demonstrates that total gastrectomy and esophagectomy offer similar overall survival rates for Siewert type II adenocarcinoma patients. Factors such as tumor size, severe morbidity, and stage 4a significantly impact survival. Locally advanced disease is associated with worse survival. Total gastrectomy and esophagectomy yield comparable overall survival rates in Siewert type II esophagogastric adenocarcinoma. Severe morbidity is a critical factor affecting survival and should be carefully considered when selecting the surgical approach. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Gastric adenocarcinoma incidence is decreasing in industrialized nations and worldwide; conversely, the percentage of cancer located in the proximal stomach, especially the esophagogastric junction (EGJ), is rising. Besides, despite increased knowledge of cancer nature and evolved neoadjuvant therapies, surgery is the only potentially curative option for all types of gastric cancer treatment. Moreover, the optimal surgical option has been debated since Siewert et al. defined the classification of EGJ cancers [ 1 ]. According to this classification, Type I or distal esophageal adenocarcinoma is defined as the epicenter of the tumor 1 to 5 cm over the Z line; type II or true cardia carcinoma is if the tumor epicenter is located between 1 cm over and 2 cm under the Z line and last one is type III or subcardial tumors are located 2 to 5 cm under the Z line [ 1 ]. There is a consensus about treatment for type I and III cancers in the recent literature and guidelines; in other words, trending surgical options are neoadjuvant therapy followed by esophagectomy for type I adenocarcinomas and gastrectomy for type III adenocarcinomas[ 2 – 6 ]. Esophagectomy or total gastrectomy can be a surgical option for Siewert type II EGJ adenocarcinoma patients. Although minimally invasive or conventional, transthoracic or transhiatal esophagectomies and proximal, total, or extended total gastrectomies are defined as surgical treatments for Siewert type II EGJ adenocarcinomas, there are ongoing controversies about which surgical approach has lesser morbidities and better oncological outcomes[ 5 , 7 – 10 ]. We aimed in this study to asses optimal surgical treatment for Siewert type II EGJ adenocarcinoma in light of our real-world data, and the study's primary objective is to evaluate and compare total gastrectomy with esophagectomy techniques for treating patients with Siewert type II EGJ adenocarcinoma in terms of overall survival, mortality, anastomosis failure, and complication rates. The study's secondary goal is to assess the overall survival and effecting factors of surgically treated patients with Siewert type II EGJ adenocarcinoma survival. Methodology Patients Between 2011 and 2021, 1015 patients underwent esophagectomy and total gastrectomy according to the electronic medical record system (EMRS) of the Hacettepe University Hospital (Nucleus Medical information systems v.9.38.61, Monad Software, Ankara/ Turkiye). After reviewing patients' pathologic reports, tumors other than adenocarcinomas, Type I and Type III Siewert adenocarcinomas, and patients with esophagogastrectomies, recurrence, emergency, and minimally invasive surgeries were excluded; as a result, 160 patients with Siewert type II EGJ adenocarcinoma was extracted. The follow-up data of 21 patients was unreachable, and final analyses were performed on the data of 139 patients. Transhiatal esophagectomy was performed on eight patients, transthoracic esophagectomy was conducted on 12 patients, and McKweon esophagectomy was performed on one patient (Fig. 1 ). Patients' 27 different variables, such as age, gender, American Society of Anaesthesiologists physical status classification (ASA) Scores, neoadjuvant and adjuvant chemotherapy and radiotherapy status, Charlson comorbidity index( CCI), surgery type, tumor size, lymph node status, stage, length of stay, Clavien Dindo classification, mortality status, Follow-up duration, etc., all variables obtained from EMRS records Surgical Technique All esophagectomies and total gastrectomies were performed by 12 academic surgeons of the department with similar techniques during time intervals. The term total gastrectomy includes D2 dissection ( celiac trunk, common hepatic artery, left gastric artery, and splenic artery lymph nodes), and all types of esophagectomies include celiac lymph nodes and lower thoracic paraesophageal lymph node dissection. The surgeons preferred surgical techniques(gastrectomy or esophagectomy) according to their own familiarity Definitions All pathologic data obtained from patients' final pathologic report after the operation and the 8th edition of the American Joint Committee on Cancer TNM staging system for esophagus and esophagogastric junction cancer was used for staging [ 11 ]. Locally advanced disease is defined as stage 2b and above According to the pathology report, R1 resection is defined as carcinoma invasion of any of the surgical margins (proximal, distal, or circumferential). Preoperative comorbidity states of patients were presented as CCI scores, and the overall physical state of patients was presented as ASA scores in the study. Postoperative morbidity conditions of patients were graded with the Clavien Dindo Classification, and severe morbidity was defined as grade 3 and above in the Clavien Dindo Classification. Mortality in 30 days is defined as the mortality state of patients after the first 30 days of postoperative surgery, and mortality in 90 days is defined as the mortality state of patients after the first 90 days of postoperative surgery. During follow-up intervals, recurrence was defined as new tumor development in sites of anastomosis line or remote organs ( Liver, periton, or bones). Statistical Analysis Statistical analysis was performed with the SPSS software (Version 23, IBM, New York/ United States). Categorical variables were shown as percentages and categorical variables were analyzed using the chi-square test. Quantitative variables with normal distribution were presented as mean (± standard deviation), and the student t test was performed. Quantitative variables that did not comply with normal distribution were presented as median [interquartile range], and the Mann-Whitney U test was used. The Kaplan-Meier test was performed for survival analysis. Estimated survival time was described as median (Standard Error (SE) and 95% Confidence Interval (CI)). The Long Rank test was used to compare survival curves. The multivariate and univariate analyses were conducted using the Cox proportional hazard model. Covariates significant in the univariate analysis were included in a multivariate model. All of the two-sided tests were statistically significant, with a p-value below 0.05. This article complied with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines, and the STROBE checklist has been applied to the article[ 12 ]. Hacettepe University Health Sciences Research Ethics Committee has ethically approved this study (Project number: GO 21/1223) Results In total, 139 Siewert type II EGJ carcinoma patients were included in this study, with a mean age of 61.58 (± 10.70) years. Most patients were male: 19 (90.5%) in the esophagectomy group and 88 (74.5%) in the total gastrectomy group. In the cohort, the median length of stay in the hospital (LoS) was 10[ 11 ] days, and the anastomotic failure and severe morbidity rates were 12.3% and 31.7%, respectively; however, median LoS days (p < 0.01), anastomotic failure (p < 0.001), and severe morbidity (p < 0.05) rates of patients who underwent esophagectomy were significantly more than those who underwent total gastrectomy. In contrast, mortality in 30 days and mortality in 90 days did not differ between the total gastrectomy and the esophagectomy groups. The total mortality in the 30-day rate was 3.6%, and mortality in the 90-day rate was 8.6%. The tumor size of patients who underwent gastrectomy was significantly larger than patients who underwent esophagectomy (median tumor size 5.5[4.0] versus 3.5[4.0], p < 0.05). Median total and metastatic lymph node numbers were 18[ 17 ] and 3[ 7 ], respectively, and there were no significant differences between the groups (p = 0.17). The majority of the patients (89.2%) had locally advanced disease. Because most of the patients had locally advanced disease, all analyses were also performed in this cohort. Baseline clinical and pathological characteristics of Siewert type II EGJ carcinoma patients after esophagectomy and total gastrectomy are shown in Table 1 . Table 1 Baseline clinical and pathological characteristics of patients with Siewert type -II carcinoma after esophagectomy and total gastrectomy Esophagectomy (n = 21) Total Gastrectomy (n = 118) Total *p value Age 63.3 (± 9) 61.3 (± 11) 61.58(± 10) 0.43 Sex 0.16 Female 2 (1.4%) 30 (21.6%) 32 (23%) Male 19 (13.7%) 88 (63.3%) 107 (77%) Neoadjuvant Chemotherapy 10(7.2%) 31 (22.3%) 41 (29.5%) 0.68 Neoadjuvant Radiotherapy 0 (0%) 2 (1.4%) 2 (1.4%) 0.72 ASA Score 0.19 ASA 1 1 (0.7%) 12 (8.6%) 13(9.4%) ASA 2 8 (5.8%) 54 (38.8%) 62(44.6%) ASA 3 7 (5.0%) 42 (30.2%) 49(35.3%) ASA 4 5 (3.6%) 10 (7.2%) 15(10.8%) Charlson Comorbidity Index 5[ 3 ] 4[ 2 ] 4[ 3 ] 0.18 Resection completeness 0.59 R0 16 (11.5%) 90 (64.7%) 106 (76.3%) R1 5 (3.6%) 28 (20.1%) 33 (23.7%) Tumor Size (cm) 3.5[4.0] 5.5 [4.0] 5[ 4 ] < 0.05 Tumor Size Status(pT) 0.55 pT0 2 (1.4%) 2 (1.4%) 4 (2.9%) pT1 2 (1.4%) 5 (3.6%) 7 (5%) pT2 1 (0.7%) 10 (7.2%) 11 (7.9%) pT3 9 (6.5%) 38 (27.3%) 47 (33.8%) pT4 7 (5%) 63 (%45.3) 70 (50.4%) Total Lymph Nodes Numbers 14[ 19 ] 19 [ 16 ] 18[ 17 ] 0.10 Metastatic Lymph Node Numbers 1[ 5 ] 4[ 7 ] 3[ 7 ] 0.17 Lymph Node Status (pN) 0.28 pN0 5 (3.6%) 27 (19.4%) 32 (23%) pN1 7 (5%) 21 (15.1%) 28 (20.1%) pN2 6 (4.3%) 34 (24.5%) 40 (28.8%) pN3 3 (2.2%) 36 (25.9%) 39 (28.1%) Stage 0.43 Stage 1a 3 (2.2%) 5 (3.6%) 8 (5.8%) Stage 1b 1 (0.7%) 2 (1.4%) 3 (2.2%) Stage 2a 0(0%) 4 (2.9%) 4 (2.9%) Stage 2b 1 (0.7%) 7 (5.0%) 8 (5.8%) Stage 3a 1 (0.7%) 3 (2.2%) 4 (2.9%) Stage 3b 9 (6.5%) 45 (32.4%) 54 (38.8%) Stage 4a 6 (4.3%) 52 (37.4%) 58 (41.7%) Locally Advanced Disease 17 (12.2%) 107 (77%) 124 (89.2%) 0.24 Adjuvant Chemotherapy 14 (10.1%) 73 (52.5%) 87 (62.6%) 0.80 Adjuvant Radiotherapy 9 (6.5%) 35 (25.2%) 44 (31.7%) 0.30 LoS (Days) 21[31] 10[ 8 ] 10[ 11 ] < 0.01 Clavien Dindo Classification < 0.05 Grade 0 1 (0.7%) 34 (24.5%) 35 (25.2%) Grade 1 3 (2.2%) 10 (7.2%) 13 (9.4%) Grade 2 4 (2.9%) 43 (30.9%) 47 (33.8%) Grade 3 7 (5.0%) 18 (12.9%) 25 (18.0%) Grade 4 4 (2.9%) 10 (7.2%) 14 (10.1%) Grade 5 2 (1.4%) 3 (2.2%) 5 (3.6%) Severe Morbidity 13 (9.4%) 31(22.3%) 44 (31.7%) < 0.05 Anastomotic Failure 10 (7.2%) 8 (5.8%) 18 (12.9%) < 0.001 Mortality (30 days) 2 (1.4%) 3 (2.2%) 5 (3.6%) 0.16 Mortality (90 days) 2 (1.4%) 10 (7.2%) 12 (8.6%) 0.57 Recurrence 5 (3.6%) 26 (19%) 31 (22.6%) 0.88 Follow-up Duration (Months) 24[30] 29[43] 28[40] 0.39 ASA: American Society of Anesthesiologists; pT, pN, and stage indicate TNM staging classification due to final pathology report (AJCC 8th edition), LoS: Length of stay in hospital *Bold p values represent significance In the locally advanced disease group, tumor size (5.5[3.5] cm vs. 4[4.8]cm, p < 0.05) was more extensive, and severe morbidity rate (24% versus 7%, p < 0.05) was higher in the total gastrectomy group in the meanwhile, anastomosis failure rate (6.4% versus 5.6%, p < 0.01) was higher and LoS ( 23[31] days versus 10[ 9 ] days, p < 0.01) was longer in the esophagectomy group. The other variables had no differences between the esophagectomy and the total gastrectomy groups. Survival Analyses The median survival time was 30 (SE: 4.48 and 95%CI: 21.2–38.7) months, the two-year overall survival rate was 57.4%, and the five-year survival rate was 38.7% regardless of surgery type. Median survival time was 30 (SE: 4.88 95%CI: 20.4–39.5) months, the two-year overall survival rate was 57.6%, and the five-year overall survival rate was 38.3% after total gastrectomy and median survival time was 30 (SE: 5.53 95%CI: 19.1–40.8) months, the two-year overall survival rate was 56.4% and the five-year overall survival rate was 43.9% after esophagectomy patients. Survival rates of esophagectomy seemed better than total gastrectomy; however, there was no significance between the two types of surgery in the overall survival rates (p = 0.891) (Fig. 2 ). The five-year overall survival rate was 34.5% for the locally advanced disease group, and the five-year overall survival rate was 73.3% for the non-locally advanced disease group, and there was a significant difference in overall survival rates (p < 0.05) the patients with locally advanced disease and non-locally advanced disease (Fig. 3 ) The median survival time in the locally advanced group was 29 (SE: 3.328 95%CI: 22.477–35.523) months. Five-year overall survival rates were 34.5% for esophagectomy and 34.6% for total gastrectomy, and there was no significance between the two types of surgery in the overall survival rates among patients with locally advanced disease (p = 0.931) (Fig. 4 ). Prognostic factors of overall survival Resection completeness, LoS, Clavien Dindo Grade 4, severe morbidity, tumor size, metastatic lymph node count, lymph node state(pN2 and pN3), stage 4a, locally advanced disease, and developing recurrence were associated with poor survival for Siewert type II EGJ carcinomas in univariate analyses. Multivariate analysis was conducted with the results that were significant in the univariate analysis, eleven factors, and finally, Clavien Dindo Grade 4, tumor size, and stage 4a were detected as independent prognostic factors for Siewert type II EGJ carcinomas in multivariate analysis(Table 2 ). Table 2 Prognostic factors of overall survival (univariate and multivariate analysis). LoS: Length of stay in hospital HR 95%CI p HR 95%CI p Completeness of Resection 2.208 1.390–3.506 < 0.01 LoS 1.014 1.004–1.025 < 0.05 Clavien Dindo Grade 4 2.590 1.203–5.578 < 0.05 3.900 1.536–9.901 < 0.05 Severe Morbidity 0.537 0.344–0.837 < 0.01 Tumor Size 1.113 1.046–1.186 < 0.01 1.093 1.009–1.183 < 0.05 Metastatic Lymph Node Count 1.027 1.001–1.055 < 0.05 Lymph Node Status pN2 2.403 1.234–4.680 < 0.05 pN3 2.670 1.385–5.150 < 0.01 Stage < 0.01 Stage 4a 4.636 1.121–19.167 < 0.05 6.303 1.068–37.201 < 0.05 Locally advance disease 3.103 1.135–8.482 < 0.05 Recurrence 1.969 1.225–3.164 < 0.01 Table 3 Prognostic factors of overall survival (univariate and multivariate analysis)in locally advanced disease. HR 95%CI p HR 95%CI p Completeness of Resection 1.862 1.155–3.000 < 0.05 LoS 1.026 1.014–1.038 < 0.001 Clavien Dindo Grade 4 4.269 1.943–9.382 < 0.001 0.148 0.148 − 0.025 < 0.05 Severe Morbidity 0.493 0.313–0.778 < 0.01 0.032 0.004–0.253 < 0.01 Tumor Size 1.093 1.022–1.170 < 0.05 1.097 1.009–1.193 < 0.05 Total Lymph Node Count 0.981 0.962–0.999 < 0.05 0.972 0.950–0.993 < 0.05 Lymph Node State pN3 2.220 1.048–4.702 < 0.05 Recurrence 0.568 0.350–0.921 < 0.05 LoS: Length of stay in hospital In patients with locally advanced disease, resection completeness, LoS, Clavien Dindo Grade 4, severe morbidity, tumor size, total lymph node count, pN3 lymph node status, and developing recurrence were associated with poor survival for Siewert type II EGJ Carcinomas in univariate analyses. In multivariate analyses, Clavien Dindo Grade 4, severe morbidity, tumor size, and total lymph node count were detected as independent prognostic factors. Discussion This study evaluated the survival analysis of patients with Siewert type II EGJ carcinoma or true cardia tumor who underwent surgery between 2011 and 2022, showing that overall five-year survival was 38.7% and either total gastrectomy or esophagectomy was not superior to each other when compared in terms of two-year and five-year and overall survival rates. Tumor size (HR:1.093, 95%CI: 1.009–1.183, p < 0.05), grade 4 morbidity (HR: 3.900, 95%CI: 1.536–9.901, p < 0.05) and stage 4a disease (HR: 6.303, 95%CI: 1.068–37.201, p < 0.05) are found as independent prognostic factors of Siewert type II EGJ carcinoma. Our study also showed that esophagectomy is significantly associated with longer length of stay( 21[31] vs. 10[ 8 ] days p < 0.01) and more anastomosis failure ( 7.2% versus 5.8% p < 0.001) to compare total gastrectomy on the contrary severe morbidity more occurred after total gastrectomy (22.3% versus 9.4% p < 0.05). However, the two approaches have similar mortality rates in 30 and 90 days. The same results were also obtained from the locally advanced group. However, patients with locally advanced disease have worse survival rates than those with non-locally advanced disease. (34.5% versus 73.3%, p < 0.05). Although studies evaluating EGJ carcinomas are few, analyses of the survival of Siewert type II EGJ carcinomas alone are fewer, and there are no concluded prospective analyses to date[ 7 , 13 – 19 ]. The five-year survival rate was 27% for Siewert type II EGJ carcinoma in the original study of Siewert and Stein [ 20 ]. Recent publications show that the median overall survival is 29–38 months, and the five-year overall survival rates are 37–55%, regardless of surgical approaches[ 7 , 13 , 15 , 18 , 19 ]. Despite the heterogeneity of our cohort, results are comparable with recent studies. There are contradictious results in the literature for better surgical options for patients with Siewert type II EGJ carcinoma. Siewert and Stein [ 20 ] indicated that extended gastrectomy with complete tumor resection has a favorable five-year survival rate compared to subtotal esophagectomy; two-year survival of total gastrectomy was slightly better than esophagectomy, but no difference was detected (57.6% versus 56.4% p = 0.891) in our cohort. On the contrary, a single-center study [ 15 ] shows that transthoracic esophagectomy has a longer overall median survival time than extended total gastrectomy (38 versus 33 months p < 0.05). The registry-based study[ 16 ], which includes almost 10,000 patients, indicates that esophagectomy has overall survival advantages when compared to total gastrectomy( 53% versus 47% p < 0.001). Although the five-year overall survival of esophagectomy is more than total gastrectomy, this result is not significantly different ( 43.9% versus 38.3% p = 0.891). Other recent studies [ 13 , 18 , 21 , 22 ] did not show any overall survival advantages between total gastrectomy and esophagectomy like the result we achieved. Besides overall survival, oncologic outcomes such as achieving complete resection, optimal lymphadenectomy, and morbidity and mortality rates also affect the preference for surgery [ 3 , 10 ]. In our study, the resection completeness (R0) rate is 76.3%, and there is no difference between esophagectomy and total gastrectomy, and resection completeness is not a prognostic factor for patients with Siewert type II EGJ carcinoma in multivariate analysis. Some studies showed that the microscopically incomplete resection (R1) rate increases after total gastrectomy, but this finding is also not associated with prognosis [ 18 , 23 ]. However, Voron et al. indicated that while there was no difference between total gastrectomy and esophagectomy groups in terms of incomplete resection, incomplete resection was an independent risk factor for poor survival in multivariate analysis (HR: 3.138, 95%CI: 1.711–5.758, p < 0.001). These discrepancies may caused by the heterogeneity of studies and the role of adjuvant therapies. Optimal lymph node count and extent of dissection is another ongoing debate in Siewert type II EGJ carcinoma. In our study, total and metastatic lymph node counts were similar in the esophagectomy and the total gastrectomy groups, and we indicated that pN2, pN3 status, and metastatic and total lymph node counts are risk factors for survival in univariate analysis; however, only total lymph node count is an independent risk factor for patients with locally advanced Siewert type II EGJ carcinoma in multivariate analysis. The novel study of Yamashita et al. showed that patients with three or more positive nodes or pN3 tumors had the worst five-year survival rates (22.4% and 17.4%, respectively) in Siewert type II EGJ carcinoma [ 7 ]. In this study, overall mortality in 30 and 90 days were 3.6% and 8.6%, respectively, and no significant differences existed between the esophagectomy and total gastrectomy groups. However, the esophagectomy group has slightly higher anastomosis failure and length of stay, and the total gastrectomy group has a higher severe morbidity rate. Voron et al. Found that Clavien-Dindo grade 3 or higher morbidity was a decisive prognostic factor for survival (HR: 4.054, 95%CI: 2.416–6.802, p < 0.001) in multivariate analysis [ 12 ]. However, previous extensive retrospective studies and recent systematic reviews confirm similar mortality and morbidity results and did not indicate an association between morbidity and survival rate [ 8 , 14 , 16 , 18 , 22 ]. Blank et al., although overall survival rates did not evaluate between the locally advanced group and non-locally advanced group, showed that their 242-patient cohort, thoracoabdominal esophagectomy with pN status independent prognostic factor for patients with locally advanced Siewert type II EGJ carcinoma[ 15 ]. Patients with locally advanced disease have worse survival, and surgery type or pN status was not associated with survival in multivariate analyses in our cohort. Pioneer studies such as MAGIC and CROSS showed a better prognosis in subgroup analyses of patients with Siewert type II EGJ carcinoma, and once again, our results emphasize the necessity of neoadjuvant therapies for Siewert type II EGJ carcinoma [ 24 , 25 ]. Our study has major limitations—the most important being its retrospective nature and limited patient cohort. Disease-free survival, an important finding, could not be calculated due to the low number of patients enrolled in the esophagectomy cohort. The heterogeneity of neoadjuvant and adjuvant therapies should also be considered, as approximately 90% of patients have advanced-stage diseases, and the groups were heterogeneous regarding neoadjuvant and adjuvant therapies. In conclusion, our data shows that the total gastrectomy or the esophagectomy has no survival and mortality advantages against each other in patients with Siewert type II EGJ carcinomas; the locally advanced disease has poorer survival, and the occurrence of severe morbidity is an independent risk factor for survival. These results indicate that patient selection and the postoperative course could be more important than selecting a surgical approach in Siewert type II EGJ carcinoma. Abbreviations EGJ: esophagogastric junction ASA: American Society of Anaesthesiologists CCI: Charlson comorbidity index CI: Confidence Interval LoS: Length of stay Declarations Acknowledgement Ethics Hacettepe University Health Sciences Research Ethics Committee has ethically approved this study (Project number: GO 21/1223). Written informed consent was obtained from all of the patients who participated in this study. Funding Declaration The authors have also disclosed that this study did not receive any financial support from any organization, institution, or individual. Conflict of Interest The authors have ensured there are no conflicts of interest associated with this study. Data Availibility The data supporting the findings of this study are available upon reasonable request. Author Contribution M.S data curation, formal analysis, methodology. N.A conceptualization, formal analysis, supervision, writing-editing, figures and tables.All authors reviewed the manuscript. 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Dis Esophagus, 1996(9): p. 173–82. Kneuertz PJ, et al. Long-Term Survival in Patients with Gastroesophageal Junction Cancer Treated with Preoperative Therapy: Do Thoracic and Abdominal Approaches Differ? Ann Surg Oncol. 2016;23(2):626–32. Jezerskyte E, et al. Gastrectomy Versus Esophagectomy for Gastroesophageal Junction Tumors: Short- and Long-Term Outcomes From the Dutch Upper Gastrointestinal Cancer Audit. Ann Surg. 2022;276(6):e735–43. Parry K, et al. Surgical treatment of adenocarcinomas of the gastro-esophageal junction. Ann Surg Oncol. 2015;22(2):597–603. Cunningham D, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11–20. Shapiro J, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16(9):1090–8. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4530102","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314481757,"identity":"ea514f54-30e6-4636-a758-b6cabf69b6cf","order_by":0,"name":"Muhammed Salih Süer","email":"","orcid":"","institution":"etlik city hospital","correspondingAuthor":false,"prefix":"","firstName":"Muhammed","middleName":"Salih","lastName":"Süer","suffix":""},{"id":314481758,"identity":"6a2309ba-2e26-400f-9671-fd65dfa227aa","order_by":1,"name":"Nezih Akkapulu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYDACHjYQacHAL4EiSliLBIPkDBCdYADXIkFQi8ENYrXw9xxL/FzYJpG4+Xbzww8ff/yRM2dvYHzwto2hzrwBuxaJs22HpWcCtWy7c8xYckaCgbFlzwFmw7ltDBIyB3BYc569QZoXpOVGghkzT4JB4oYbCWxAEQYJXC6TP8/e/BukZfOM9G/MfxIM6jfcf8D+G58Wg7Ntx8C2bJDIMWMGej8BGA5szPi0GJ45lmY945yE8YwbOcWSPWnGhjt7Epsl55yTgIQ6FiB3Js34dkGZjWz/jPSNH37YyMmbsx8++OFNmQ0/7ohhYGBGdSoDYwMDvpjEpmUUjIJRMApGASoAAOiXVWa59QbnAAAAAElFTkSuQmCC","orcid":"","institution":"Hacettepe University","correspondingAuthor":true,"prefix":"","firstName":"Nezih","middleName":"","lastName":"Akkapulu","suffix":""}],"badges":[],"createdAt":"2024-06-04 19:59:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4530102/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4530102/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60188647,"identity":"ac3eca33-e02a-46c7-a5ff-6fa62d12e478","added_by":"auto","created_at":"2024-07-12 19:16:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34922,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4530102/v1/05079249b92ca7a90d6f9a03.png"},{"id":60189033,"identity":"0c3b2f4d-fd59-4978-81a6-e0534610c735","added_by":"auto","created_at":"2024-07-12 19:24:22","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202795,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4530102/v1/78d4ce502fa2f214b9185276.jpeg"},{"id":60188649,"identity":"bf56b0c7-4e13-4c4c-94e5-c5afdd6932d3","added_by":"auto","created_at":"2024-07-12 19:16:22","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":190203,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4530102/v1/2fd67cedf260240e8b3e2f4c.jpeg"},{"id":60188650,"identity":"48aa9000-9d0b-4ea1-b37c-7656f6986f71","added_by":"auto","created_at":"2024-07-12 19:16:23","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":212056,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4530102/v1/00c33b13b7421ed61bc687a0.jpeg"},{"id":82385726,"identity":"82701757-3d72-44d0-a023-6a95e13db880","added_by":"auto","created_at":"2025-05-09 16:31:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1406876,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4530102/v1/b3f88c54-c505-44a4-b985-cfc02b2e9776.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Esophagectomy versus Total Gastrectomy for Siewert Type II Esophagogastric Junction Adenocarcinoma: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGastric adenocarcinoma incidence is decreasing in industrialized nations and worldwide; conversely, the percentage of cancer located in the proximal stomach, especially the esophagogastric junction (EGJ), is rising. Besides, despite increased knowledge of cancer nature and evolved neoadjuvant therapies, surgery is the only potentially curative option for all types of gastric cancer treatment.\u003c/p\u003e \u003cp\u003eMoreover, the optimal surgical option has been debated since Siewert et al. defined the classification of EGJ cancers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to this classification, Type I or distal esophageal adenocarcinoma is defined as the epicenter of the tumor 1 to 5 cm over the Z line; type II or true cardia carcinoma is if the tumor epicenter is located between 1 cm over and 2 cm under the Z line and last one is type III or subcardial tumors are located 2 to 5 cm under the Z line [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. There is a consensus about treatment for type I and III cancers in the recent literature and guidelines; in other words, trending surgical options are neoadjuvant therapy followed by esophagectomy for type I adenocarcinomas and gastrectomy for type III adenocarcinomas[\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEsophagectomy or total gastrectomy can be a surgical option for Siewert type II EGJ adenocarcinoma patients. Although minimally invasive or conventional, transthoracic or transhiatal esophagectomies and proximal, total, or extended total gastrectomies are defined as surgical treatments for Siewert type II EGJ adenocarcinomas, there are ongoing controversies about which surgical approach has lesser morbidities and better oncological outcomes[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We aimed in this study to asses optimal surgical treatment for Siewert type II EGJ adenocarcinoma in light of our real-world data, and the study's primary objective is to evaluate and compare total gastrectomy with esophagectomy techniques for treating patients with Siewert type II EGJ adenocarcinoma in terms of overall survival, mortality, anastomosis failure, and complication rates.\u003c/p\u003e \u003cp\u003eThe study's secondary goal is to assess the overall survival and effecting factors of surgically treated patients with Siewert type II EGJ adenocarcinoma survival.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eBetween 2011 and 2021, 1015 patients underwent esophagectomy and total gastrectomy according to the electronic medical record system (EMRS) of the Hacettepe University Hospital (Nucleus Medical information systems v.9.38.61, Monad Software, Ankara/ Turkiye). After reviewing patients' pathologic reports, tumors other than adenocarcinomas, Type I and Type III Siewert adenocarcinomas, and patients with esophagogastrectomies, recurrence, emergency, and minimally invasive surgeries were excluded; as a result, 160 patients with Siewert type II EGJ adenocarcinoma was extracted. The follow-up data of 21 patients was unreachable, and final analyses were performed on the data of 139 patients. Transhiatal esophagectomy was performed on eight patients, transthoracic esophagectomy was conducted on 12 patients, and McKweon esophagectomy was performed on one patient (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients' 27 different variables, such as age, gender, American Society of Anaesthesiologists physical status classification (ASA) Scores, neoadjuvant and adjuvant chemotherapy and radiotherapy status, Charlson comorbidity index( CCI), surgery type, tumor size, lymph node status, stage, length of stay, Clavien Dindo classification, mortality status, Follow-up duration, etc., all variables obtained from EMRS records\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique\u003c/h2\u003e \u003cp\u003eAll esophagectomies and total gastrectomies were performed by 12 academic surgeons of the department with similar techniques during time intervals. The term total gastrectomy includes D2 dissection ( celiac trunk, common hepatic artery, left gastric artery, and splenic artery lymph nodes), and all types of esophagectomies include celiac lymph nodes and lower thoracic paraesophageal lymph node dissection. The surgeons preferred surgical techniques(gastrectomy or esophagectomy) according to their own familiarity\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDefinitions\u003c/h2\u003e \u003cp\u003eAll pathologic data obtained from patients' final pathologic report after the operation and the 8th edition of the American Joint Committee on Cancer TNM staging system for esophagus and esophagogastric junction cancer was used for staging [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLocally advanced disease is defined as stage 2b and above\u003c/p\u003e \u003cp\u003eAccording to the pathology report, R1 resection is defined as carcinoma invasion of any of the surgical margins (proximal, distal, or circumferential).\u003c/p\u003e \u003cp\u003ePreoperative comorbidity states of patients were presented as CCI scores, and the overall physical state of patients was presented as ASA scores in the study.\u003c/p\u003e \u003cp\u003ePostoperative morbidity conditions of patients were graded with the Clavien Dindo Classification, and severe morbidity was defined as grade 3 and above in the Clavien Dindo Classification.\u003c/p\u003e \u003cp\u003eMortality in 30 days is defined as the mortality state of patients after the first 30 days of postoperative surgery, and mortality in 90 days is defined as the mortality state of patients after the first 90 days of postoperative surgery.\u003c/p\u003e \u003cp\u003eDuring follow-up intervals, recurrence was defined as new tumor development in sites of anastomosis line or remote organs ( Liver, periton, or bones).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed with the SPSS software (Version 23, IBM, New York/ United States). Categorical variables were shown as percentages and categorical variables were analyzed using the chi-square test. Quantitative variables with normal distribution were presented as mean (\u0026plusmn;\u0026thinsp;standard deviation), and the student t test was performed. Quantitative variables that did not comply with normal distribution were presented as median [interquartile range], and the Mann-Whitney U test was used. The Kaplan-Meier test was performed for survival analysis. Estimated survival time was described as median (Standard Error (SE) and 95% Confidence Interval (CI)). The Long Rank test was used to compare survival curves. The multivariate and univariate analyses were conducted using the Cox proportional hazard model. Covariates significant in the univariate analysis were included in a multivariate model. All of the two-sided tests were statistically significant, with a p-value below 0.05.\u003c/p\u003e \u003cp\u003eThis article complied with The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines, and the STROBE checklist has been applied to the article[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Hacettepe University Health Sciences Research Ethics Committee has ethically approved this study (Project number: GO 21/1223)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 139 Siewert type II EGJ carcinoma patients were included in this study, with a mean age of 61.58 (\u0026plusmn;\u0026thinsp;10.70) years. Most patients were male: 19 (90.5%) in the esophagectomy group and 88 (74.5%) in the total gastrectomy group.\u003c/p\u003e \u003cp\u003eIn the cohort, the median length of stay in the hospital (LoS) was 10[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] days, and the anastomotic failure and severe morbidity rates were 12.3% and 31.7%, respectively; however, median LoS days (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), anastomotic failure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and severe morbidity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) rates of patients who underwent esophagectomy were significantly more than those who underwent total gastrectomy.\u003c/p\u003e \u003cp\u003eIn contrast, mortality in 30 days and mortality in 90 days did not differ between the total gastrectomy and the esophagectomy groups. The total mortality in the 30-day rate was 3.6%, and mortality in the 90-day rate was 8.6%.\u003c/p\u003e \u003cp\u003eThe tumor size of patients who underwent gastrectomy was significantly larger than patients who underwent esophagectomy (median tumor size 5.5[4.0] versus 3.5[4.0], p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Median total and metastatic lymph node numbers were 18[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and 3[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], respectively, and there were no significant differences between the groups (p\u0026thinsp;=\u0026thinsp;0.17). The majority of the patients (89.2%) had locally advanced disease. Because most of the patients had locally advanced disease, all analyses were also performed in this cohort.\u003c/p\u003e \u003cp\u003eBaseline clinical and pathological characteristics of Siewert type II EGJ carcinoma patients after esophagectomy and total gastrectomy are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline clinical and pathological characteristics of patients with Siewert type -II carcinoma after esophagectomy and total gastrectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEsophagectomy\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal Gastrectomy\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*p value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.3 (\u0026plusmn;\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.3 (\u0026plusmn;\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.58(\u0026plusmn;\u0026thinsp;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (13.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (63.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (22.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (29.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62(44.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (30.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49(35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson Comorbidity Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResection completeness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (64.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e106 (76.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5[4.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5 [4.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size Status(pT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (%45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (50.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Lymph Nodes Numbers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic Lymph Node Numbers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph Node Status (pN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (15.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (28.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 2a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 2b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 3b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (37.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocally Advanced Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124 (89.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant Chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (10.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (52.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 (62.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant Radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoS (Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21[31]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Dindo Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (10.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere Morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(22.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic Failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (90 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (22.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up Duration (Months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24[30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29[43]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28[40]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eASA: American Society of Anesthesiologists; pT, pN, and stage indicate TNM staging classification due to final pathology report (AJCC 8th edition), LoS: Length of stay in hospital\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Bold p values represent significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the locally advanced disease group, tumor size (5.5[3.5] cm vs. 4[4.8]cm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) was more extensive, and severe morbidity rate (24% versus 7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) was higher in the total gastrectomy group in the meanwhile, anastomosis failure rate (6.4% versus 5.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) was higher and LoS ( 23[31] days versus 10[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) was longer in the esophagectomy group. The other variables had no differences between the esophagectomy and the total gastrectomy groups.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurvival Analyses\u003c/h2\u003e \u003cp\u003eThe median survival time was 30 (SE: 4.48 and 95%CI: 21.2\u0026ndash;38.7) months, the two-year overall survival rate was 57.4%, and the five-year survival rate was 38.7% regardless of surgery type.\u003c/p\u003e \u003cp\u003eMedian survival time was 30 (SE: 4.88 95%CI: 20.4\u0026ndash;39.5) months, the two-year overall survival rate was 57.6%, and the five-year overall survival rate was 38.3% after total gastrectomy and median survival time was 30 (SE: 5.53 95%CI: 19.1\u0026ndash;40.8) months, the two-year overall survival rate was 56.4% and the five-year overall survival rate was 43.9% after esophagectomy patients. Survival rates of esophagectomy seemed better than total gastrectomy; however, there was no significance between the two types of surgery in the overall survival rates (p\u0026thinsp;=\u0026thinsp;0.891) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe five-year overall survival rate was 34.5% for the locally advanced disease group, and the five-year overall survival rate was 73.3% for the non-locally advanced disease group, and there was a significant difference in overall survival rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) the patients with locally advanced disease and non-locally advanced disease (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe median survival time in the locally advanced group was 29 (SE: 3.328 95%CI: 22.477\u0026ndash;35.523) months. Five-year overall survival rates were 34.5% for esophagectomy and 34.6% for total gastrectomy, and there was no significance between the two types of surgery in the overall survival rates among patients with locally advanced disease (p\u0026thinsp;=\u0026thinsp;0.931) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePrognostic factors of overall survival\u003c/h2\u003e \u003cp\u003eResection completeness, LoS, Clavien Dindo Grade 4, severe morbidity, tumor size, metastatic lymph node count, lymph node state(pN2 and pN3), stage 4a, locally advanced disease, and developing recurrence were associated with poor survival for Siewert type II EGJ carcinomas in univariate analyses.\u003c/p\u003e \u003cp\u003eMultivariate analysis was conducted with the results that were significant in the univariate analysis, eleven factors, and finally, Clavien Dindo Grade 4, tumor size, and stage 4a were detected as independent prognostic factors for Siewert type II EGJ carcinomas in multivariate analysis(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrognostic factors of overall survival (univariate and multivariate analysis). LoS: Length of stay in hospital\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleteness of Resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.390\u0026ndash;3.506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.004\u0026ndash;1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Dindo Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.590\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.203\u0026ndash;5.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.536\u0026ndash;9.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere Morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.344\u0026ndash;0.837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.046\u0026ndash;1.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.009\u0026ndash;1.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic Lymph Node Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.001\u0026ndash;1.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph Node Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.234\u0026ndash;4.680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.385\u0026ndash;5.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.121\u0026ndash;19.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.068\u0026ndash;37.201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocally advance disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.135\u0026ndash;8.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.225\u0026ndash;3.164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrognostic factors of overall survival (univariate and multivariate analysis)in locally advanced disease.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleteness of Resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.155\u0026ndash;3.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.014\u0026ndash;1.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Dindo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.943\u0026ndash;9.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.148\u0026thinsp;\u0026minus;\u0026thinsp;0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere Morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.313\u0026ndash;0.778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.004\u0026ndash;0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.022\u0026ndash;1.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.009\u0026ndash;1.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Lymph Node Count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.962\u0026ndash;0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.950\u0026ndash;0.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph Node State\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.048\u0026ndash;4.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.350\u0026ndash;0.921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eLoS: Length of stay in hospital\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn patients with locally advanced disease, resection completeness, LoS, Clavien Dindo Grade 4, severe morbidity, tumor size, total lymph node count, pN3 lymph node status, and developing recurrence were associated with poor survival for Siewert type II EGJ Carcinomas in univariate analyses. In multivariate analyses, Clavien Dindo Grade 4, severe morbidity, tumor size, and total lymph node count were detected as independent prognostic factors.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the survival analysis of patients with Siewert type II EGJ carcinoma or true cardia tumor who underwent surgery between 2011 and 2022, showing that overall five-year survival was 38.7% and either total gastrectomy or esophagectomy was not superior to each other when compared in terms of two-year and five-year and overall survival rates. Tumor size (HR:1.093, 95%CI: 1.009\u0026ndash;1.183, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), grade 4 morbidity (HR: 3.900, 95%CI: 1.536\u0026ndash;9.901, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and stage 4a disease (HR: 6.303, 95%CI: 1.068\u0026ndash;37.201, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) are found as independent prognostic factors of Siewert type II EGJ carcinoma.\u003c/p\u003e \u003cp\u003eOur study also showed that esophagectomy is significantly associated with longer length of stay( 21[31] vs. 10[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] days p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and more anastomosis failure ( 7.2% versus 5.8% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) to compare total gastrectomy on the contrary severe morbidity more occurred after total gastrectomy (22.3% versus 9.4% p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, the two approaches have similar mortality rates in 30 and 90 days. The same results were also obtained from the locally advanced group. However, patients with locally advanced disease have worse survival rates than those with non-locally advanced disease. (34.5% versus 73.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAlthough studies evaluating EGJ carcinomas are few, analyses of the survival of Siewert type II EGJ carcinomas alone are fewer, and there are no concluded prospective analyses to date[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The five-year survival rate was 27% for Siewert type II EGJ carcinoma in the original study of Siewert and Stein [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Recent publications show that the median overall survival is 29\u0026ndash;38 months, and the five-year overall survival rates are 37\u0026ndash;55%, regardless of surgical approaches[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Despite the heterogeneity of our cohort, results are comparable with recent studies.\u003c/p\u003e \u003cp\u003eThere are contradictious results in the literature for better surgical options for patients with Siewert type II EGJ carcinoma. Siewert and Stein [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] indicated that extended gastrectomy with complete tumor resection has a favorable five-year survival rate compared to subtotal esophagectomy; two-year survival of total gastrectomy was slightly better than esophagectomy, but no difference was detected (57.6% versus 56.4% p\u0026thinsp;=\u0026thinsp;0.891) in our cohort. On the contrary, a single-center study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] shows that transthoracic esophagectomy has a longer overall median survival time than extended total gastrectomy (38 versus 33 months p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The registry-based study[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which includes almost 10,000 patients, indicates that esophagectomy has overall survival advantages when compared to total gastrectomy( 53% versus 47% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although the five-year overall survival of esophagectomy is more than total gastrectomy, this result is not significantly different ( 43.9% versus 38.3% p\u0026thinsp;=\u0026thinsp;0.891). Other recent studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] did not show any overall survival advantages between total gastrectomy and esophagectomy like the result we achieved.\u003c/p\u003e \u003cp\u003eBesides overall survival, oncologic outcomes such as achieving complete resection, optimal lymphadenectomy, and morbidity and mortality rates also affect the preference for surgery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, the resection completeness (R0) rate is 76.3%, and there is no difference between esophagectomy and total gastrectomy, and resection completeness is not a prognostic factor for patients with Siewert type II EGJ carcinoma in multivariate analysis. Some studies showed that the microscopically incomplete resection (R1) rate increases after total gastrectomy, but this finding is also not associated with prognosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, Voron et al. indicated that while there was no difference between total gastrectomy and esophagectomy groups in terms of incomplete resection, incomplete resection was an independent risk factor for poor survival in multivariate analysis (HR: 3.138, 95%CI: 1.711\u0026ndash;5.758, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These discrepancies may caused by the heterogeneity of studies and the role of adjuvant therapies.\u003c/p\u003e \u003cp\u003eOptimal lymph node count and extent of dissection is another ongoing debate in Siewert type II EGJ carcinoma. In our study, total and metastatic lymph node counts were similar in the esophagectomy and the total gastrectomy groups, and we indicated that pN2, pN3 status, and metastatic and total lymph node counts are risk factors for survival in univariate analysis; however, only total lymph node count is an independent risk factor for patients with locally advanced Siewert type II EGJ carcinoma in multivariate analysis. The novel study of Yamashita et al. showed that patients with three or more positive nodes or pN3 tumors had the worst five-year survival rates (22.4% and 17.4%, respectively) in Siewert type II EGJ carcinoma [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, overall mortality in 30 and 90 days were 3.6% and 8.6%, respectively, and no significant differences existed between the esophagectomy and total gastrectomy groups. However, the esophagectomy group has slightly higher anastomosis failure and length of stay, and the total gastrectomy group has a higher severe morbidity rate. Voron et al. Found that Clavien-Dindo grade 3 or higher morbidity was a decisive prognostic factor for survival (HR: 4.054, 95%CI: 2.416\u0026ndash;6.802, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in multivariate analysis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, previous extensive retrospective studies and recent systematic reviews confirm similar mortality and morbidity results and did not indicate an association between morbidity and survival rate [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBlank et al., although overall survival rates did not evaluate between the locally advanced group and non-locally advanced group, showed that their 242-patient cohort, thoracoabdominal esophagectomy with pN status independent prognostic factor for patients with locally advanced Siewert type II EGJ carcinoma[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Patients with locally advanced disease have worse survival, and surgery type or pN status was not associated with survival in multivariate analyses in our cohort. Pioneer studies such as MAGIC and CROSS showed a better prognosis in subgroup analyses of patients with Siewert type II EGJ carcinoma, and once again, our results emphasize the necessity of neoadjuvant therapies for Siewert type II EGJ carcinoma [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study has major limitations\u0026mdash;the most important being its retrospective nature and limited patient cohort. Disease-free survival, an important finding, could not be calculated due to the low number of patients enrolled in the esophagectomy cohort. The heterogeneity of neoadjuvant and adjuvant therapies should also be considered, as approximately 90% of patients have advanced-stage diseases, and the groups were heterogeneous regarding neoadjuvant and adjuvant therapies.\u003c/p\u003e \u003cp\u003eIn conclusion, our data shows that the total gastrectomy or the esophagectomy has no survival and mortality advantages against each other in patients with Siewert type II EGJ carcinomas; the locally advanced disease has poorer survival, and the occurrence of severe morbidity is an independent risk factor for survival. These results indicate that patient selection and the postoperative course could be more important than selecting a surgical approach in Siewert type II EGJ carcinoma.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEGJ: esophagogastric junction\u003c/p\u003e\n\u003cp\u003eASA: American Society of Anaesthesiologists\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCCI: Charlson comorbidity index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI: Confidence Interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLoS: Length of stay\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHacettepe University Health Sciences Research Ethics Committee has ethically approved this study (Project number: GO 21/1223). Written informed consent was obtained from all of the patients who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding Declaration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have also disclosed that this study did not receive any financial support from any organization, institution, or individual.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have ensured there are no conflicts of interest associated with this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availibility\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available upon reasonable request.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.S data curation, formal analysis, methodology. N.A conceptualization, formal analysis, supervision, writing-editing, figures and tables.All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiewert JR, Becker HA, Gossner K. Kardiakarzinom. Versuch einer therapeutisch relevanten klassifikation. Chirurg. 1987;58:25\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Groot EM et al. Trends in surgical techniques for the treatment of esophageal and gastroesophageal junction cancer: the 2022 update. Dis Esophagus, 2023. 36(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolscher AH, Law S. Esophagogastric junction adenocarcinomas: individualization of resection with special considerations for Siewert type II, and Nishi types EG, E\u0026thinsp;=\u0026thinsp;G and GE cancers. Gastric Cancer. 2020;23(1):3\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumamoto T, et al. True esophagogastric junction adenocarcinoma: background of its definition and current surgical trends. Surg Today. 2020;50(8):809\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWirsik NM et al. \u003cem\u003eImpact of the Surgical Approach for Neoadjuvantly Treated Gastro-Esophageal Junction type II Tumors- a Multi-National, High-Volume Center Retrospective Cohort Analysis.\u003c/em\u003e Ann Surg, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddavid R, et al. Transhiatal distal esophagectomy for Siewert type II cardia cancer can be a treatment option in selected patients. Eur J Surg Oncol. 2019;45(10):1943\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamashita H, et al. Optimal extent of lymph node dissection for Siewert type II esophagogastric junction carcinoma. Ann Surg. 2011;254(2):274\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTseng J, Posner MC. For Gastroesophageal Junction Cancers, Does an Esophageal or Gastric Surgical Approach Offer Better Perioperative and Oncologic Outcomes? Ann Surg Oncol. 2020;27(2):511\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinoshita T, et al. Laparoscopic transhiatal resection for Siewert type II adenocarcinoma of the esophagogastric junction: operative technique and initial results. Surg Laparosc Endosc Percutan Tech. 2012;22(4):e199\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDevaud N, Carroll P. Ongoing Controversies in Esophageal Cancer II: Gastrectomy versus Esophagectomy for Siewert Type II Esophageal Adenocarcinoma. Thorac Surg Clin. 2022;32(4):553\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRice TW, et al. Cancer of the Esophagus and Esophagogastric Junction: An Eighth Edition Staging Primer. J Thorac Oncol. 2017;12(1):36\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoron T, et al. Adenocarcinoma of the oesophagogastric junction Siewert II: An oesophageal cancer better cured with total gastrectomy. Eur J Surg Oncol. 2019;45(12):2473\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOh SE, et al. Comparison of transabdominal and transthoracic surgical approaches in the treatment of Siewert type II esophagogastric junction cancers: A propensity score-matching analysis. Eur J Surg Oncol. 2022;48(2):370\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlank S, et al. Surgical strategies in true adenocarcinoma of the esophagogastric junction (AEG II): thoracoabdominal or abdominal approach? Gastric Cancer. 2018;21(2):303\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamarajah SK, et al. Esophagectomy or Total Gastrectomy for Siewert 2 Gastroesophageal Junction (GEJ) Adenocarcinoma? A Registry-Based Analysis. Ann Surg Oncol. 2021;28(13):8485\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeers JM, et al. The CARDIA-trial protocol: a multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II. BMC Cancer. 2020;20(1):781.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Pasqual CA et al. Transthoracic esophagectomy compared to transhiatal extended gastrectomy for adenocarcinoma of the esophagogastric junction: a multicenter retrospective cohort study. Dis Esophagus, 2022. 35(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImamura Y, et al. Esophagogastric junction adenocarcinoma shares characteristics with gastric adenocarcinoma: Literature review and retrospective multicenter cohort study. Ann Gastroenterol Surg. 2021;5(1):46\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiewert JRaS. H.J., Carcinoma of cardia: carcinoma of the gastroesophageal junction- classification, pathology and extent of resection. Dis Esophagus, 1996(9): p. 173\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKneuertz PJ, et al. Long-Term Survival in Patients with Gastroesophageal Junction Cancer Treated with Preoperative Therapy: Do Thoracic and Abdominal Approaches Differ? Ann Surg Oncol. 2016;23(2):626\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJezerskyte E, et al. Gastrectomy Versus Esophagectomy for Gastroesophageal Junction Tumors: Short- and Long-Term Outcomes From the Dutch Upper Gastrointestinal Cancer Audit. Ann Surg. 2022;276(6):e735\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParry K, et al. Surgical treatment of adenocarcinomas of the gastro-esophageal junction. Ann Surg Oncol. 2015;22(2):597\u0026ndash;603.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCunningham D, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro J, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16(9):1090\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4530102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4530102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe incidence of gastric adenocarcinoma is declining, while cases located in the proximal stomach are increasing. Surgery remains the primary curative treatment option for gastric cancer. Debate persists regarding the optimal surgical approach for Siewert type II esophagogastric junction adenocarcinoma. This study aims to assess the outcomes of these surgical options based on real-world data, evaluating overall survival, mortality, anastomosis failure and complication rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2001 and 2021, 1015 patients underwent esophagectomy and total gastrectomy. After exclusions, 139 patients with Siewert type II adenocarcinoma were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 139 patients, the median age was 61.58 years, with a predominance of males. Total gastrectomy had a shorter hospital stay (p\u0026lt;0.01) and lower rates of anastomosis failure (p\u0026lt;0.001) and severe morbidity (p\u0026lt;0.05) compared to esophagectomy. Mortality rates at 30 and 90 days did not differ between the two groups. Tumor size was larger in the gastrectomy group (p\u0026lt;0.05). Locally advanced disease was predominant (89.2%). Overall five-year survival was 38.7%, with no significant difference between surgical approaches (p=0.891).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study demonstrates that total gastrectomy and esophagectomy offer similar overall survival rates for Siewert type II adenocarcinoma patients. Factors such as tumor size, severe morbidity, and stage 4a significantly impact survival. Locally advanced disease is associated with worse survival. Total gastrectomy and esophagectomy yield comparable overall survival rates in Siewert type II esophagogastric adenocarcinoma. Severe morbidity is a critical factor affecting survival and should be carefully considered when selecting the surgical approach.\u003c/p\u003e","manuscriptTitle":"Esophagectomy versus Total Gastrectomy for Siewert Type II Esophagogastric Junction Adenocarcinoma: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 19:16:18","doi":"10.21203/rs.3.rs-4530102/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"42221265-8544-4080-b63f-616fe36daf11","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T16:23:37+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 19:16:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4530102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4530102","identity":"rs-4530102","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}