Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis

Abstract

Background Chemoradiation followed by resection has been the standard therapy for resectable (cT1-4aN0-3M0) esophageal carcinoma in the Netherlands since 2010. The optimal surgical approach remains a matter of debate. Therefore, the purpose of this study was to compare the transhiatal and the transthoracic approach concerning morbidity, mortality and oncological quality. Methods Data was acquired from the Dutch Upper GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma (cT1-4aN0-3M0) from 2011 to 2016 were included. Patients who underwent a transthoracic and transhiatal esophagectomy were compared after propensity score matching. Results After propensity score matching, 1532 of 4143 patients were included for analysis. The transthoracic approach yielded more lymph nodes (transthoracic median 19, transhiatal median 14; p < 0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher in the transthoracic group (p = 0.044). The transthoracic group experienced more chyle leakage (9.7% vs. 2.7%, p < 0.001), more pulmonary complications (35.5% vs. 26.1%, p < 0.001), and more cardiac complications (15.4% vs. 10.3%, p = 0.003). The transthoracic group required a longer hospital stay (median 14 vs. 11 days, p < 0.001), ICU stay (median 3 vs. 1 day, p < 0.001), and had a higher 30-day/in-hospital mortality rate (4.0% vs. 1.7%, p = 0.009). Conclusions In a propensity score-matched cohort, the transthoracic esophagectomy provided a more extensive lymph node dissection, which resulted in a higher lymph node yield, at the cost of increased morbidity and short-term mortality.

Neoadjuvant Chemoradiotherapy Followed by Transhital Esophagectomy in Locally Advanced Esophageal Squamous Cell Carcinoma: Impact of Pathological Complete Response

“…However, since then, with the finding that the neoadjuvant regimen with Paclitaxel + Carboplatin has shown to have a better pathological response rate, this has been the protocol used in the Service, meaning that in the future, the casuistic will be more expressive and may add a better survival rate disease-free and 5-year survival. In addition, transhiatal esophagectomy showed acceptable rates of postoperative complications and in accordance with the literature 17,25 , therefore, still indicated in selected cases.…”

Evaluating the Cost for Robotic vs “Non-Robotic” Transhiatal Esophagectomy

“…While arguments about the superiority of transthoracic vs transhiatal esophagectomy has raged for decades and is beyond this report, this study of our robotic experience is notable for our data on costs and outcomes. 18 While esophagectomy has been traditionally performed via a "non-robotic" approach, robotic THE stands out as a novel and intriguing approach for esophageal resection. Robotic THE harnesses the advantages of the robotic platform and negates the need for thoracic incisions, with potentially lowering EBL, pulmonary complications, LOS, and shortening recovery time.…”

Surgical Therapy of Esophageal Adenocarcinoma—Current Standards and Future Perspectives

“…Generally, the transhiatal approach is an alternative to the transthoracic procedure for primary tumors located in the distal esophagus or at the gastroesophageal junction. Transthoracic surgery is considered oncologically superior as a more extended, two-field lymph node dissection can be performed [ 42 , 43 ]. On the other hand, transhiatal surgery is associated with lower postoperative complication rates (especially a lower pulmonary complication rate) and a shorter hospital stay [ 42 , 44 ].…”

“…Transthoracic surgery is considered oncologically superior as a more extended, two-field lymph node dissection can be performed [ 42 , 43 ]. On the other hand, transhiatal surgery is associated with lower postoperative complication rates (especially a lower pulmonary complication rate) and a shorter hospital stay [ 42 , 44 ]. Next to surgeon preferences, the existence and location of lymph node metastases also plays part in the decision for either transhiatal or transthoracic surgery.…”