AMSTERDAM—Currently, one of two surgical approaches can be used for patients with esophageal adenocarcinoma located distal to the carina. Cervicoabdominal (transhiatal) esophagectomy without lymphadenectomy is thought to limit short-term risks and costs. On the other hand, combined cervicothoracoabdominal (transthoracic) surgery, including dissection of peritumoral tissues and all thoracic and abdominal lymph nodes, is believed to maximize long-term survival. Because data to support either strategy have been scarce, thoracic surgeons have long debated the optimal approach.

“In this discussion, there are many personal opinions, but there are not very many hard, randomized data,” remarked J. Jan van Lanschot, MD, Professor and Chief of Surgical Oncology at the Academic Medical Center in Amsterdam. He and his colleagues therefore performed a randomized trial to compare outcomes with the two techniques. Their results confirm that morbidity is lower with transhiatal esophagectomy; whether the transthoracic approach prolongs survival remains unclear.[1]

FEWER INCISIONS, FEWER COMPLICATIONS

Transthoracic resection with removal of all thoracic and abdominal lymph nodes requires a third, lateral thoracic incision and thus is more extensive than transhiatal surgery, which involves only cervical and abdominal incisions. “Our hypothesis was that if you prevent the third incision—you only explore from the neck and the abdomen, and you dissect the esophagus from below—you will probably see fewer perioperative complications,” said Dr. van Lanschot. He acknowledged, however, that even if “the more extensive procedure has more perioperative complications, it still could be the best operation, because … you might see more long-term survival.”

To compare the approaches, the researchers performed transhiatal or transthoracic esophagectomy on 93 and 109 patients, respectively. Transhiatal surgery entailed significantly lower median surgery duration (3.5 vs 6 hours) and blood loss (1.0 vs 1.9 L). Additionally, transhiatal resection resulted in fewer pulmonary complications (29 vs 65) and reduced median times on mechanical ventilation (1 vs 2 days), in the ICU (2 vs 6 days), and in the hospital (15 vs 19 days).

NO SIGNIFICANT DIFFERENCE IN SURVIVAL BETWEEN GROUPS

Overall survival during a mean follow-up of 4.7 years was not significantly different between the two groups, but there was a trend toward higher survival among the transthoracic patients (10% advantage in five-year survival; confidence interval [CI], –3% to 23%). Since publication, Dr. van Lanschot and colleagues have reanalyzed the data to identify patient subpopulations that might receive additional benefit from transthoracic surgery. Patients whose tumors were limited to the esophagus appeared to gain significantly with the transthoracic procedure (18% advantage in five-year survival; CI, 7% to 29%), “whereas the patients who have tumors in the proximal part of the stomach or at the gastroesophageal junction don’t have this advantage,” he noted.

Therefore, Dr. van Lanschot recommended, “You should try and individualize your choice to the patient—if you have a patient with a tumor in the proximal part of the stomach invading the distal esophagus, you should favor the minimal, transhiatal resection. If you have a patient with a truly esophageal tumor, you should favor the transthoracic resection, which is more invasive and harder for the patient but gives a truly larger result in the long term.” Furthermore, young patients might be better candidates for transthoracic resection. He said, “If you have an older patient with a higher operative risk, you might go for the transhiatal approach.”

—Mimi Zucker, PhD

References
1. Hulscher JBF, van Sandick JW, de Boer AGEM, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347:1662-1669.

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