Extended Transthoracic Resection Compared With Limited Transhiatal Resection for Adenocarcinoma of the Mid/Distal Esophagus

Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Annals of Surgery (Impact Factor: 8.33). 01/2008; 246(6):992-1000; discussion 1000-1. DOI: 10.1097/SLA.0b013e31815c4037
Source: PubMed

ABSTRACT To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival.
A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available.
A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy.
After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02).
There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.

1 Follower
  • Current Surgery 01/2002; 59(1):12-7. DOI:10.1016/S0149-7944(01)00559-1
  • [Show abstract] [Hide abstract]
    ABSTRACT: The ability to predict both short-term and long-term outcome after esophagectomy for cancer is invaluable. It helps us to select the appropriate patients for esophagectomy, to modify surgical procedures or perioperative care to lessen the chance of adverse events, and to decide if neoadjuvant or adjuvant therapies are of value. Predictors of morbidity and mortality after esophagectomy can include many individual factors or their combinations in the form of mathematical scores. Long-term prognosis depends to a large extent on disease stage, but the surgeon can play a major role as well, by minimizing postoperative complications and by performing a R0 resection with extended lymphadenectomy. The accuracy of prediction is improving as technology advances and understanding of the disease becomes more thorough. Information gained should be used for better individualized patient care.
    Esophagus 12/2009; 6(4):215-219. DOI:10.1007/s10388-009-0211-2 · 0.74 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: AimsWide acceptance of laparoscopic esophagectomy has been hampered by the technical difficulty of the procedure and inconsistent improvements in morbidity and mortality. Most case series have utilized a combined thoracoscopic–laparoscopic approach (TLE), but laparoscopic inversion esophagectomy (LIE), a method of transhiatal esophagectomy, has been proposed as an alternative. Inversion esophagectomy simplifies retraction and improves exposure during the mediastinal dissection; however, no previous studies have directly compared LIE outcomes with those of the combined approach. MethodsBetween July 2003 and March 2008, 70 consecutive patients underwent minimally invasive esophagectomy by LIE (N=40) or TLE (N=30). Data for all patients were collected prospectively and stored in a relational database. Recorded outcome measures included operative time, blood loss, length of hospital stay, intensive care unit stay, and perioperative complications. ResultsThere were no significant differences in patient age, gender, body mass index (BMI), or American Society of Anesthesiologists (ASA) class between the groups, but LIE patients had lower stage of esophageal cancer, and were less likely to have received induction chemoradiotherapy than TLE patients. Patients undergoing LIE had significantly lower operative time (398 vs. 537min, p<0.001), intraoperative blood loss (100 vs. 200ml, p<0.001), and overall length of stay (9 vs. 14days, p=0.003) compared with TLE patients. LIE yielded a median of 10 lymph nodes removed compared with 13 for TLE (p=0.016). Atrial arrhythmia and postoperative pneumonia were less common in LIE patients than in TLE patients, occurring in 17.5% vs. 27.1% (p=0.036), and in 7.5% vs. 15.7% of cases (p=0.029), respectively. ConclusionLIE provides safe and effective approach to minimally invasive esophagectomy for patients with early esophageal cancer and high-grade dysplasia. Compared with TLE, inversion esophagectomy requires less operative time and has lower operative blood loss and length of hospital stay. LIE may also result in fewer perioperative cardiac and pulmonary complications compared with TLE. Based on these results, we reserve TLE for more advanced esophageal cancer and those undergoing preoperative radiochemotherapy.
    Surgical Endoscopy 09/2009; 23(9):2147-2154. DOI:10.1007/s00464-008-0249-6 · 3.31 Impact Factor
Show more