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. 2021 Jan;28(1):175-183.
doi: 10.1245/s10434-020-08760-8. Epub 2020 Jun 30.

Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis

Alexander C Mertens  1   2 , Marianne C Kalff  1 , Wietse J Eshuis  1 , Thomas M Van Gulik  1 , Mark I Van Berge Henegouwen  1 , Suzanne S Gisbertz  3 ; Dutch Upper GI Cancer Audit group
Affiliations

Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis

Alexander C Mertens et al. Ann Surg Oncol. 2021 Jan.

Abstract

Background: Chemoradiation followed by resection has been the standard therapy for resectable (cT1-4aN0-3M0) esophageal carcinoma in the Netherlands since 2010. The optimal surgical approach remains a matter of debate. Therefore, the purpose of this study was to compare the transhiatal and the transthoracic approach concerning morbidity, mortality and oncological quality.

Methods: Data was acquired from the Dutch Upper GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma (cT1-4aN0-3M0) from 2011 to 2016 were included. Patients who underwent a transthoracic and transhiatal esophagectomy were compared after propensity score matching.

Results: After propensity score matching, 1532 of 4143 patients were included for analysis. The transthoracic approach yielded more lymph nodes (transthoracic median 19, transhiatal median 14; p < 0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher in the transthoracic group (p = 0.044). The transthoracic group experienced more chyle leakage (9.7% vs. 2.7%, p < 0.001), more pulmonary complications (35.5% vs. 26.1%, p < 0.001), and more cardiac complications (15.4% vs. 10.3%, p = 0.003). The transthoracic group required a longer hospital stay (median 14 vs. 11 days, p < 0.001), ICU stay (median 3 vs. 1 day, p < 0.001), and had a higher 30-day/in-hospital mortality rate (4.0% vs. 1.7%, p = 0.009).

Conclusions: In a propensity score-matched cohort, the transthoracic esophagectomy provided a more extensive lymph node dissection, which resulted in a higher lymph node yield, at the cost of increased morbidity and short-term mortality.

Keywords: Esophagectomy; Neoplasms; Transhiatal; Transthoracic; Upper gastrointestinal tract.

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Conflict of interest statement

Van Berge Henegouwen reports to be a consultant for Johnson & Johnson, Medtronic, Stryker, and Mylan, in addition to institutional grants from Stryker and Olympus. The remaining have no conflict of interest to report.

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