Transhiatal esophagectomy: clinical experience and refinements

Abstract

Objective: To review the authors' clinical experience with transhiatal esophagectomy (THE) and the refinements in this procedure that have evolved.

Background: Increased use of THE during the past two decades has generated controversy about the merits and safety of this approach compared with transthoracic esophageal resection. The authors' large THE experience provides a valuable basis for benchmarking data regarding the procedure.

Methods: The results of THE were analyzed retrospectively using the authors' prospectively established esophageal resection database and follow-up information on these patients.

Results: From 1976 to 1998, THE was performed in 1085 patients, 26% with benign disease and 74% with cancer. The procedure was possible in 98.6% of cases. Stomach was the esophageal substitute in 96%. The hospital mortality rate was 4%. Blood loss averaged 689 cc. Major complications were anastomotic leak (13%), atelectasis/pneumonia (2%), intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (<1% each). Actuarial survival of patients with carcinoma equaled or exceeded that reported after transthoracic esophagectomy. Late functional results were good or excellent in 70%. With preoperative pulmonary and physical conditioning, a side-to-side stapled cervical esophagogastric anastomosis (<3% incidence of leak), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of stay reduced to 7 days.

Conclusion: THE is possible in most patients requiring esophageal resection and can be performed with greater safety and fewer complications than the traditional transthoracic approaches.

Figure 1. Kaplan-Meier actuarial survival curve of 800 patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia.

Figure 2. Site-dependent Kaplan-Meier survival curves in patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia.

Figure 3. Kaplan-Meier survival curve in patients receiving chemotherapy and radiation therapy before transhiatal esophagectomy.

Figure 4. Stage-dependent Kaplan-Meier actuarial survival curves in patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia.

Figure 5. Histology-dependent Kaplan-Meier survival curves in patients undergoing transhiatal esophagectomy for carcinoma of the intrathoracic esophagus and cardia.