C. Takahashi1, R. Shridhar2, J. Huston3, K. Meredith4 1National Naval Medical Center,Surgery,Portsmouth, VIRGINIA, USA 2Florida Hospital Cancer Institute,Radiation Oncology,Orlando, FLORIDA, USA 3Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FLORIDA, USA 4Florida State University College Of Medicine/ Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FL, USA
Introduction: Surgical resection has become a mainstay of therapy for esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic (TT) versus transhiatal (TH) esophagectomy.
Methods: A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. Propensity score matching was perfomred based upon age and stage. Statistical analysis was performed using SPSS® version 23.0 (IBM®, Chicago, IL). Continuous variables were compared using the Kruskal Wallis or the ANOVA tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test.
Results: We identified 846 patients who underwent esophagectomy with a mean age of 64 ± 10 years. There was no difference in EBL for TT and TH, but the mean OR times were longer for TT vs. TH (p<0.001) and the number of retrieved lymph nodes was higher for TT vs. TH (p<0.002). Post-operative complications occurred in 207 (29.0%) patients who underwent a TT approach versus 59 (44.7%) who underwent a TH approach, (p<0.001). The most common complications in TT versus TH techniques respectively were anastomotic leaks: 4.3% versus 9.8%, (p=0.01), anastomotic stricture 7% versus 26.5%, (p<0.001) and pneumonia 12.6% versus 22.7%, (p<0.002). Other outcomes that were also improved in TT vs. TH were aspiration (p<0.001), wound infections (p=0.004), and pleural effusions (p<0.001). Median survival was also significantly improved in patients undergoing TT (62 months) vs TH (39 months) p=0.03. After matching there were 131 in the TT and 131 in the TH groups. Post-operative complications remained lower in the TT (32.1%) vs TH (44.3%), p=0.04. Among these, anastomotic strictures (p<0.001), pulmonary complications (p=0.006), aspirations (p<0.001), and pleural effusions (p<0.001) were all lower in the transthoracic cohorts. There were lower incidences of anastomotic leaks in the TT 6 (4.6%) vs TH 13(9.9%), p=0.09 and wound infections: TT 6 (4.6%) vs TH 14(10.7%) p=0.06 which did not reach significance.
Conclusion: In this modern propensity score matched analysis of transthoracic versus transhiatal esophagectomy we found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections and strictures with an improvement in nodal harvest. Survival was also significantly improved in patients who underwent transthoracic esophagectomy.