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Transhiatal esophagectomy

Brechtje A. Grotenhuis, Bas P. L. Wijnhoven and J. Jan B. Van Lanschot

INTRODUCTION

It is widely recognized that a surgical procedure such as esophagectomy has lower mortality and morbidity rates when performed in high volume centers. Nevertheless, esophagectomy is still associated with a substantial operative risk. For a continuous improvement of outcomes, optimization of the surgical approach for patients with esophageal cancer has been the focus of many studies over the last years.

Two major surgical approaches in case of esophagectomy for cancer have emerged in the past decades: (1) a more limited surgical procedure with regional lymphadenectomy only (transhiatal esophagectomy—THE), and (2) radical esophagectomy with extended lymphadenectomy (transthoracic esophagectomy—TTE). THE was first performed in 1933 by the British surgeon Turner, by blunt dissection and pull-through of the esophagus. In the decades thereafter, THE was not popularized because the transthoracic approach was preferred after the introduction of general anesthesia and artificial ventilation techniques that made chest surgery feasible. In 1978, Orringer and Sloan described their initial series of blunt THE, after which interest in the procedure was rekindled.

WHEN TO PERFORM A TRANSHIATAL ESOPHAGECTOMY

THE, with regional lymphadenectomy only, primarily aims for minimal surgical trauma and thus for improvement of short-term outcome by means of decreased morbidity and mortality. On the contrary, TTE aims to improve locoregional control and long-term survival by performing a wide excision of the tumor in combination with an en bloc lymph node dissection in both the posterior mediastinum and the upper abdomen. A well-recognized advantage of an extended resection is improved pathological lymph node staging, leading to a potential shift from falsely node-negative patients to correctly node-positive patients: the so-called stage migration. Many studies have been published comparing the two open procedures (THE versus TTE) with regard to postoperative morbidity and mortality, long-term survival, and staging of the tumor.

Short-term outcome: postoperative morbidity and mortality

RANDOMIZED CONTROLLED TRIALS

Few randomized studies have been conducted comparing both open surgical techniques for esophageal cancer. Most studies included a limited number of patients (between 29 and 67 subjects). However, Hulscher et al. performed a large randomized two-center trial (the “Dutch trial”). Patients with adenocarcinoma of the mid-/distal esophagus or adenocarcinoma of the gastric cardia substantially involving the distal esophagus were randomly assigned to TTE with two-field lymphadenectomy (N = 114) or limited THE (N = 106). Perioperative morbidity was higher after TTE; in particular, pulmonary complications were seen more often in patients who underwent TTE (57% after TTE versus 27% after THE, p < .001). There was no difference with regard to in-hospital mortality (4% after TTE versus 2% after THE, p = .45).

META-ANALYSES

Three meta-analyses of the English-language literature comparing TTE with THE for carcinoma of the esophagus and/ or the gastroesophageal junction have been published. These studies give an overview of the randomized controlled trials (RCTs), comparative cohort studies, and case series. The meta-analyses are summarized in Table 34.1 .

In the most recent meta-analysis, studies until 2010 were analyzed, including the Dutch RCT. According to this review, TTE took a mean of 85 minutes longer than THE (p < .001).

There was no significant difference in blood loss. The postoperative length of hospital stay in patients who underwent THE was, on average, 4 days less than in patients who underwent TTE (p < .01). TTE was associated with a higher risk of respiratory complications (36% after TTE versus 28% after THE, p = .02), but not with an increased cardiac risk (p = .86). Vocal cord paralysis and anastomotic leakage were more frequent after THE. The mortality rate, defined as 30-day mortality or in-hospital mortality, was significantly higher after TTE (odds ratio 1.48, 95% confidence interval 1.20-1.83, p = 0.001).

Long-term outcome: survival

RANDOMIZED CONTROLLED TRIALS

The Dutch trial did not detect a statistically significant difference in survival, but it is possible this was a type II statistical error. After TTE and THE 5-year survival rates were 36% and 34%, respectively (p = 0.71). In a subgroup analysis based on the location of the primary tumor, no overall survival benefit for either surgical approach was seen in 115 patients with a type II junctional tumor (TTE 27% versus THE 31%, p = 0.81). However, although not statistically significant, an absolute survival benefit of 14% was seen in patients with a type I esophageal tumor with the transthoracic approach (51% versus 37%, p = 0.33). In patients (N = 55) without positive nodes, locoregional disease-free survival after THE was comparable to that after TTE (86% and 89%, respectively). The same was true for patients (N = 46) with more than eight positive nodes (0% in both groups). However, patients (N = 104) with one to eight positive lymph nodes in the resection specimen showed a 5-year disease-free survival advantage if operated via the transthoracic route (TTE 64% versus THE 23%, p = 0.02). It was concluded that there was no significant overall survival benefit for either approach, but TTE with extended lymphadenectomy for patients with type I esophageal adenocarcinoma, particularly when there were a limited number of positive lymph nodes in their resection specimen, showed an ongoing trend toward better 5-year survival.

META-ANALYSES

There was no significant difference in long-term survival between TTE and THE resections in all three meta-analyses (see Table 34.1 ).

Effect on staging and the role of neoadjuvant chemoradiotherapy

TTE with extended lymphadenectomy may offer better insight in the lymphatic dissemination of tumor cells. Dissecting more lymph nodes increases the chance of finding a tumor-positive node, which may influence pathological staging (stage migration). On the contrary, due to a limited regional lymphadenectomy with the inferior pulmonary veins as the most cranial extension of the mediastinal lymphadenectomy, patients who undergo THE may be falsely staged as node-negative when positive nodes in the upper and middle part of the chest have not been dissected. The diagnostic yield of an extended lymphadenectomy has been studied. Some 37% of patients who underwent TTE showed tumor-positive nodes in extended fields. Extended resection led to tumor upstaging in 23% of patients; however, this was mainly due to positive nodes at the celiac trunk (20%), which can also be effectively resected during THE.

Proponents of an extended resection with en bloc lymphadenectomy argued that the number of removed lymph nodes appeared to be an independent predictor of survival after esophagectomy for cancer. However, in the light of the recently published large multicenter RCT by van Hagen et al., which showed that preoperative chemoradiotherapy (CRT) improves survival, one can question whether these findings are still valid. Besides a high pathologically complete response rate of 29% and a significantly higher rate of complete R0 resection after preoperative CRT, it was found that this neoadjuvant regime frequently leads to sterilization of locoregional lymph nodes. Lymph node positivity in the resection specimen was found in 50 patients (31%) after CRT, as compared with 120 patients (75%) in the surgery-alone group (p < .001).

Since this trial was published, it has been questioned whether extended lymphadenectomy after neoadjuvant CRT is still indicated for prognostic and/or therapeutic reasons. A more recent study in the same randomized study population explored the association between the total number of resected nodes and survival in patients with or without neoadjuvant CRT. In the surgery-alone group, a positive association was identified between number of resected nodes and number of resected positive nodes. However, this association was absent in patients treated with neoadjuvant CRT followed by surgery (see Figure 34.1 ). More important, total number of resected nodes was significantly associated with survival for patients in the surgery-alone arm (hazard ratio [HR] = 0.76; p = .007), but not in the multimodality arm (HR = 1.00; p = .98). These data question the indication for maximization of lymphadenectomy after neoadjuvant CRT.

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