Two thousand transhiatal esophagectomies: changing trends, lessons learned

Abstract

Objective: "Rediscovered" in 1976, transhiatal esophagectomy (THE) has been applicable in most situations requiring esophageal resection and reconstruction. The objective of this study was to review the authors' 30-year experience with THE and changing trends in its use.

Methods: Using the authors' prospective Esophagectomy Database, this single institution experience with THE was analyzed retrospectively.

Results: Two thousand and seven THEs were performed-1063 (previously reported) between 1976 and 1998 (group I) and 944 from 1998 to 2006 (group II), 24% for benign disease, 76%, cancer. THE was possible in 98%. Stomach was the esophageal substitute in 97%. Comparing outcomes between group I and group II, statistically significant differences (P < 0.001) were observed in hospital mortality (4% vs. 1%); adenocarcinoma histology (69% vs. 86%); use of neoadjuvant chemoradiation (28% vs. 52%); mean blood loss (677 vs. 368 mL); anastomotic leak (14% vs. 9%); and discharge within 10 days (52% vs. 78%). Major complications remain infrequent: wound infection/dehiscence, 3%, atelectasis/pneumonia, 2%, intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration, <1% each. Late functional results have been good or excellent in 73%. Aggressive preoperative conditioning, avoiding the ICU, improved pain management, and early ambulation reduce length of stay, with 50% in group II discharged within 1 week.

Conclusion: THE refinements have reduced the historic morbidity and mortality of esophageal resection. This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients.

FIGURE 1. Kaplan-Meier actuarial survival curve of 1482 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. Differences in survival were statistically significant (P < 0.0001).

FIGURE 3. Kaplan-Meier survival curves in 583 patients who received chemotherapy and radiation therapy before THE. One hundred and twenty-five (21%) were “complete responders” (T₀N₀ tumors) whose survival was considerably better than those with residual carcinoma in the resected specimen. Differences in survival were statistically significant (P < 0.0001).

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. Differences in survival were statistically significant (P < 0.0001).