A single surgeon's series of transthoracic oesophageal resections

Abstract

Introduction: Significant controversy persists over the optimum surgical management of oesophageal carcinoma. The authors report on a consecutive personal series of open transthoracic oesophageal resections.

Methods: Data relating to resections performed between mid-1993 and the end of 2010 were analysed. Patient and tumour assessment evolved over this period. Preoperative chemotherapy in appropriate cases was introduced in 2002. A laparotomy and right lateral thoracotomy approach (Ivor-Lewis) was used. In all cases the pylorus was not interfered with, no attempt was made to perform a radical lymphadenectomy but surgical strategy was focused on producing an R0 resection and a hand sewn anastomosis was fashioned.

Results: A total of 165 resections were performed; 130 patients (80%) were male. The median age was 66 years (range: 31-82 years). Eighty per cent had an adenocarcinoma. Sixty-four per cent of the tumours were T3/T4 and sixty-two per cent node positive. Forty patients (24%) had an involved circumferential resection margin (CRM). Five patients (3.0%) had no resection and a quarter (26%) developed morbidity of some form. There was one clinical anastomotic leak (0.6%) and three benign strictures requiring dilation (1.8%). In-hospital mortality was 3.0% (5 patients). Disease specific survival at one, two and five years was 77%, 42% and 36% respectively. Neither CRM involvement nor preoperative chemotherapy influenced survival significantly. No patient required intervention to disrupt the pylorus.

Conclusions: Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.

Figure 1

Decision algorithm for the management of oesophageal cancer. CPET = cardiopulmonary exercise testing; CT = computed tomography; EUS = endoscopic ultrasonography; HGD = high grade dysplasia; MDT = multidisciplinary team; PET = positron emission tomography; PFT = pulmonary function test; OE02 = neoadjuvant chemotherapy; UGI = upper gastrointestinal.

Figure 2

Disease specific survival categorised by stage. Numbers alive at 24, 48 and 60 months: Stage 0 (n=7) = 6, 6, 6; Stage I (n=25) = 23, 19, 19; Stage II (n=41) = 25, 20, 19; Stage III (n=89) = 40, 31, 31.

Figure 3

Disease specific survival categorised by nodal status. Numbers still alive at 24, 48 and 60 months: node positive (n=104) = 50, 38, 38; node negative (n=59) = 45, 39, 38.