Evidence-Based Selective Application of Transhiatal Esophagectomy in a High-Volume Esophageal Center

Transthoracic esophagectomy (TTE) with lymphadenectomy represents the gold standard of operative approaches to esophageal cancer. The TTE procedure carries significant operative risk, particularly in patients with co-morbidities, and the possible oncologic benefit of a mediastinal lymph node dissection in certain subgroups of patients with esophageal cancer is controversial. Transhiatal esophagectomy (THE), which avoids a thoracotomy, may reduce morbidity and mortality below levels seen with TTE, and there is no proof from randomized studies of any oncologic inferiority to TTE in patients with early tumors. Accordingly, the selective use of THE has increased in our high-volume center in recent years, and this study audits that experience over the last decade

Between 2000 and 2009 inclusive, 584 patients were treated surgically with curative intent. The standard operative approach in our unit is en bloc TTE, and THE represents 5.5% overall, and 11.1% in the second 5-year period (2004–2009), compared with 2% previously. The present study details the selection of these cases (n = 32) treated with THE and their outcomes, as well as the outcomes in the TTE (n = 438) group

Transhiatal esophagectomy was used for early stage carcinoma (n = 18) and for patients of advanced age who also had co-morbidities (n = 14). Patients undergoing THE were significantly older (68.46 versus 63.07 years of age; p = 0.002), and were at higher operative risk based on ASA grade (grade 3: 53.1% versus 17.3%; p < 0.001), compared with TTE patients. The THE cohort also included more patients with early cancers compared with the TTE cohort (56.3% versus 17.6%; p < 0.001). There were no differences in R0 resection rates for patients with early tumors or advanced co-morbidity. Nodal yields were lower in THE patients (p = 0.005). The overall complication rate was lower in the THE group (31.6% versus 44.2%; p = 0.021), and there were no postoperative deaths in the transhiatal group, whereas the in-hospital mortality rate for the TTE group was 3% (p < 0.001). Disease-specific survival was equivalent with each approach.

Transhiatal esophagectomy has a role in a pragmatic individualized approach to esophageal cancer. As an alternative to a standardized en bloc transthoracic esophagectomy, the transhiatal approach may be suitable for patients with predicted node-negative cancers or those with resectable disease who are not candidates for TTE because of co-morbidity.