Elsevier

Surgery

Volume 170, Issue 1, July 2021, Pages 263-270
Surgery

Thoracic
Comparative outcomes of transthoracic versus transhiatal esophagectomy

https://doi.org/10.1016/j.surg.2021.02.036Get rights and content

Abstract

Background

Surgical resection has become a mainstay of therapy for locally advanced esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic versus transhiatal esophagectomy.

Methods

A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. Continuous variables were compared using the Kruskal-Wallis or the analysis of variance tests as appropriate. Pearson χ2 test was used to compare categorical variables. All statistical tests were 2-sided and an α (type I) error < .05 was considered statistically significant.

Results

A total of 846 patients underwent esophagectomy with a median age of 66 (28–86) years. There was no difference in estimated blood loss for transthoracic and transhiatal, but mean operating room times were longer for transthoracic versus transhiatal (P < .001), and the number of retrieved lymph nodes was higher for transthoracic versus transhiatal (P < .002). Postoperative complications occurred in 207 (29%) transthoracic patients vs 59 (44.7%) transhiatal patients, (P < .001). The most common complications in transthoracic versus transhiatal techniques, respectively, were anastomotic leaks: 4.3% vs 9.8%; (P = .01), anastomotic stricture 7% vs 26.5%; (P < .001), and pneumonia 12.6% vs 22.7%; (P < .002). Median survival significantly improved in patients undergoing transthoracic (62 months) vs transhiatal (39 months) P = .03.

Conclusion

We found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections, and strictures, with an improvement in nodal harvest. Survival was also significantly improved in patients who underwent transthoracic esophagectomy.

Introduction

Esophageal cancer is one of the deadliest cancers in the world, and despite advancements in medical care, diagnoses continue to increase in incidence every year worldwide.1 In 2020, there were 18,440 new cases of esophageal cancer and 16,170 deaths in the United States.1 The current standard of care for locally advanced esophageal cancer includes neoadjuvant chemoradiation followed by surgical resection.2 This multimodality approach has exhibited improved survival in patients with advanced nonmetastatic disease.3,4

There is no current standard of care for the surgical approach to esophagectomy for locally advanced esophageal cancer, with both open and minimally invasive techniques used.5 The myriad of techniques preclude the recommendation of a standard approach to esophageal resection. Currently the 3 most common approaches to esophagectomy are transhiatal, transthoracic (Ivor Lewis), and 3-field (McKeown). The transhiatal esophagectomy was first performed in 1933, using a midline laparotomy with left cervical incision and cervical anastomosis.6,7 The transthoracic approach, which was first described in 1946, is performed via a laparotomy and right thoracotomy with intrathoracic anastomosis.8,9 The third approach to esophagectomy is the 3-field approach or McKeown approach, which uses 3 incisions and left neck cervical anastomosis.10 Although current data suggest equivalent operative and oncologic outcomes with the varying approaches, large meta-analyses have demonstrated that a transhiatal approach has increased anastomotic leaks as well as recurrent laryngeal nerve injuries as compared to transthoracic, with other complications and long-term mortality being equal.11,12

The institution of minimally invasive approaches to esophagectomy further obscures the recommendation of a uniform technique. Biere et al published a randomized controlled trial demonstrating improved outcomes of minimally invasive esophagectomy (MIE) versus open.13 MIE has become a well-established technique, because it has demonstrated faster recovery times, decrease in blood loss, decrease in postoperative morbidity, and shorter duration of hospitalization, with comparable oncologic outcomes.9,14, 15, 16, 17 With the invention of the Da Vinci robot and its incorporation into surgical practice, robotic surgery is being investigated as a feasible and safe technique for esophagectomy. The use of thoracoscopic, laparoscopic, and robotic approaches to esophagectomy have shown to result in equivalent oncologic outcomes compared to open techniques,14,18, 19, 20 with some authors demonstrating reductions in postoperative morbidity with a robotic approach.21 We sought to investigate the difference in outcomes between transthoracic Ivor Lewis and transhiatal resections in esophageal cancer patients who undergo both open and MIE approaches.

Section snippets

Methods

A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. All patients, regardless of age, race, tumor stage or location, or neoadjuvant therapy were included in the cohort. Basic demographics, tumor characteristics, operative details, and postoperative outcomes were recorded.

Primary endpoints included perioperative adverse events (<90 days after surgery), including pneumonia, cardiac arrhythmia, deep

Overall cohort

We identified 846 patients, 714 (84.4%) who underwent transthoracic esophagectomy and 132 (15.6%) who underwent transhiatal esophagectomy with a median age of 66 (28–86). There was no difference in histology (P = .3), ethnicity (P = .7), body mass index (P = .7), preoperative stage (P = .1), or American Society of Anesthesiologists grade (P = .1) between cohorts (Table I). Additionally, there were no differences in use of neoadjuvant therapy (P = .2), EBL (P = .5), R0 resections (P = .2), or

Discussion

In this study, we used a large esophagectomy database to compare the transthoracic and transhiatal approaches to esophagectomy. We demonstrated that transthoracic has increased operative time as compared with transhiatal, especially when using MIE, but we found no difference in EBL, pathological response rates, or mortality. There was no significant difference in intraoperative complications between transthoracic and transhiatal, and MIE transthoracic actually had a greater lymph node yield

Funding/Support

The authors have indicated that they have no funding regarding the content of this article.

Conflict of interest/Disclosure

Dr Takahashi, Dr Shridhar, Dr Meredith, Ms Huston, Ms Blinn, and Ms Maramara have no conflicts of interest to disclose.

References (36)

  • P. van Hagen et al.

    Preoperative chemoradiotherapy for esophageal or junctional cancer

    New Eng J Med

    (2012)
  • M.B. Orringer et al.

    Two thousand transhiatal esophagectomies: changing trends, lessons learned

    Ann Surg

    (2007)
  • I. Lewis

    The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third

    Br J Surg

    (1946)
  • J.D. Luketich et al.

    Outcomes after minimally invasive esophagectomy: review of over 1000 patients

    Ann Surg

    (2012)
  • K.C. McKeown

    Total three-stage oesophagectomy for cancer of the oesophagus

    Br J Surg

    (1976)
  • R. Rindani et al.

    Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference?

    Aust N Z J Surg

    (1999)
  • J.D. Luketich et al.

    Minimally invasive esophagectomy: outcomes in 222 patients

    Ann Surg

    (2003)
  • A.A. Santillan et al.

    Minimally invasive surgery for esophageal cancer

    J Natl Compr Canc Netw

    (2008)
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