Cancer of the Cardia/stomach cancer/EG junction tumor

@amyfaber - due to the amount of information you will see several posts.

I’m so sorry to hear about your son’s diagnosis and the challenging journey you’re all navigating. Stage 3 cancer of the cardia at the esophagogastric junction (EGJ) with lymph node involvement is tough, and the proposed surgery—esophagectomy, gastrectomy, and colon interposition—is a complex procedure. I’ll share what I know about it based on available medical insights, focusing on the surgery, recovery, and patient experiences, while keeping things clear and empathetic. I’m not a doctor, but I can provide a detailed overview to help you understand what to expect. You might want to consider printing this and having a discussion with your doctor of specific areas you wish to review
Understanding the Surgery
The surgery your son’s team is recommending is a total esophagogastrectomy with colon interposition, typically used for advanced Siewert type II or III EGJ tumors (like your son’s, centered at the cardia or extending into the stomach). Here’s a breakdown:
Esophagectomy: Removal of part or all of the esophagus, often the distal two-thirds, to ensure the tumor and any esophageal spread are fully excised.
Gastrectomy: Removal of the entire stomach (total gastrectomy) due to the tumor’s location at the cardia and stomach involvement, plus lymph node spread.
Colon Interposition: Since the stomach is removed and can’t be used as a conduit to reconnect the digestive tract, a segment of the colon (often the transverse colon) is used to bridge the remaining esophagus to the small intestine. This restores the ability to swallow and digest food.
This is a major, high-risk surgery due to the tumor’s location at the EGJ, which sits between the chest and abdomen, and the extensive reconstruction required. It’s often performed in high-volume centers by specialized thoracic and gastrointestinal surgeons to achieve clear margins (R0 resection, meaning no visible cancer left) and remove affected lymph nodes (D2 lymphadenectomy). Your son’s 8 rounds of FLOT (a chemotherapy regimen combining fluorouracil, leucovorin, oxaliplatin, and docetaxel) plus immunotherapy likely aimed to shrink the tumor and address lymph node metastases, making surgery feasible. The fact that he can now eat is a positive sign of treatment response.
Surgical Procedure Details
Approach: The surgery may involve a thoracoabdominal approach (accessing both chest and abdomen) or a transhiatal approach (abdominal with neck incision), depending on the tumor’s extent and surgeon preference. Minimally invasive techniques (laparoscopic or robotic) might be used to reduce complications, but open surgery is common for extensive cases.
Colon Interposition: The transverse colon is preferred due to its reliable blood supply. Surgeons preserve the marginal arcade (blood vessels) to ensure the colon segment remains viable. The colon is positioned in the posterior mediastinum, connecting the esophagus to the jejunum (small intestine). Anastomoses (connections) are made at the esophagus (coloesophageal) and jejunum (colojejunal).
Lymphadenectomy: A D2 dissection removes lymph nodes around the stomach, celiac axis, and lower mediastinum to address metastases, which is critical for stage 3 disease.

Recovery Experiences
Recovery from this surgery is lengthy and challenging but varies by patient age, health, and complications. Your son, at 39, is younger than many patients (often 60+), which may improve his resilience. Here’s what to expect, based on studies and reported outcomes:
Short-Term (Hospital Stay, 2–8 Weeks)
Hospitalization: Typically 18–23 days, longer with complications. Intensive care unit (ICU) stays of 3–6 days are common for monitoring.
Complications: High morbidity (30–50%) is reported. Common issues include:
Anastomotic leaks (5–10%): Leakage at the esophagus-colon or colon-jejunum connections, which can lead to infection. Cervical anastomoses (neck) are easier to manage than thoracic ones.
Pulmonary issues (e.g., pneumonia, reintubation): More common with transthoracic approaches (up to 31% reintubation rate).
Chylothorax (lymphatic fluid leak): Rare but serious.
Graft necrosis (colon segment failure): Very rare (< 1%) with modern techniques.
Infection or sepsis: Due to the surgery’s invasiveness.
Postoperative mortality is low (2–4%) in high-volume centers but higher (up to 18%) in older studies or less experienced settings.
Nutrition: Patients can’t eat immediately. A feeding tube (jejunostomy) provides nutrition for weeks to months. Oral intake starts gradually, often with liquids, as the colon adapts to its new role. Dumping syndrome (rapid food passage causing nausea, diarrhea) is a risk post-gastrectomy.
Pain and Fatigue: Significant initially, managed with medications. Younger patients often recover stamina faster.
Long-Term (Months to Years)
Dietary Changes: Without a stomach, patients eat smaller, frequent meals (5–6 daily). The colon doesn’t store food like the stomach, so digestion is altered. Nutritional deficiencies (e.g., vitamin B12, iron) are common and require supplements. Dietitians are key for managing weight loss and malnutrition.
Quality of Life (QoL): Gastrectomy patients report better QoL than esophagectomy alone in some studies, with less reflux and swallowing issues, but colon interposition adds complexity. Reflux esophagitis is a concern, though less with colon vs. jejunal reconstruction. Patients may experience bloating, diarrhea, or bowel irregularity as the colon adapts.
Physical Recovery: Full recovery takes 6–12 months. Younger patients like your son may resume normal activities sooner, but fatigue and reduced exercise capacity are common initially.
Oncological Outcomes: Five-year survival for stage 3 EGJ cancer post-surgery ranges from 25–40%, improved by neoadjuvant therapy (like FLOT). Lymph node status and R0 resection are the biggest prognostic factors. Recurrence (often distant metastases) occurs in 40–65% of cases, typically within 2–3 years.

Here is the last part of the information

Patient Experiences
While I don’t have personal anecdotes, studies and reviews provide insights into patient experiences:
A 2017 study of nine patients undergoing total esophagogastrectomy with colon interposition reported no anastomotic leaks or graft necrosis, suggesting technical feasibility. However, complications like infections or pulmonary issues were seen
A 2008 study comparing colon vs. jejunal interposition found colon interposition had fewer long-term weight loss issues but similar complication rates. Patients reported adjusting to small, frequent meals over time, with some resuming near-normal diets by 1–2 years.
QoL studies note that younger patients adapt better to dietary changes and report higher satisfaction with eating ability compared to older patients, though psychological support is crucial for coping with body image changes and cancer recurrence fears.
Key Considerations
High-Volume Center: Outcomes are significantly better in specialized centers with experienced surgeons. Ensure your son’s team has expertise in EGJ cancer and colon interposition.
Multidisciplinary Care: Post-surgery, he’ll need ongoing support from oncologists, dietitians, and possibly psychologists to manage nutrition, monitor recurrence, and address emotional impacts.
Immunotherapy’s Role: The immunotherapy he received (e.g., checkpoint inhibitors like nivolumab) may improve survival by targeting residual cancer cells. Discuss with his oncologist whether it will continue post-surgery.
Second Opinion: Given the surgery’s complexity, a second opinion from another high-volume center (e.g., Mayo Clinic, MD Anderson) could confirm the approach or explore alternatives like proximal gastrectomy (less common for stage 3).
Clinical Trials: The CARDIA trial (ongoing) compares esophagectomy vs. gastrectomy for Siewert type II tumors, which may clarify optimal approaches in the future. Ask his team about relevant trials for stage 3 EGJ cancer.
Closing Thoughts
My heart goes out to you and your son. This surgery is daunting, but his youth, the tumor’s response to FLOT, and a skilled surgical team are all in his favor. I’d encourage joining online support groups (e.g., CancerConnect or Inspire) to connect with others who’ve undergone similar procedures for firsthand insights.

Thank you for all of the information. I really appreciate it. The whole process is daunting. He has been so brave throughout this. They do want to do surgery within approximately 6 weeks of his chemo ending which puts us at about the 3rd/4th week of May. We are meeting with the 3rd surgeon next week. Thank you for adding the patient experience as that is not anything I had been able to locate much info on. And for all of the other information. The surgeons have been open about the complications risk and there are several possibilities of complications. We think his age and his response to the FLOT, and in overall good health with the exception of the cancer, are positives. I will be following up on your suggestions. Thank you so much for the detailed information.

Would you like to get more detailed info the patient experience....if available? It's wonderful that you want to gather as much information as possible. For some of us it enhances the feeling of "control", to the extent that is possible. Would you mind sharing where you're planning surgery?

He is getting all of his treatment at Siteman in St. Louis w/ surgery at Barnes.