M. Berrata3, R. Shridhar2, P. Briceno1, S. Kucera4, A. Patel5, J. Lee1, J. Huston1, K. Meredith1 1Florida State University College Of Medicine/Sarasota Memorial Health Care System,Gastrointestinal Oncology,Sarasota, FL, USA 2University Of Central Florida,Radiation Oncology,Sarasota, FL, USA 3Florida State University College Of Medicine,Sarasota, FL, USA 4Florida State University College Of Medicine/Sarasota Memorial Health Care System,Endoscopic Oncology,Sarasota, FL, USA 5Florida Cancer Specialists,Medical Oncology,Sarasota, FL, USA
Introduction: Esophageal cancer continues to increase in incidence worldwide. The long-term survival for patients with locally advanced esophageal cancer remains poor despite improvements in multi-modality care over the last several decades. Surgical resection remains piviotal in the management of patients with esophageal cancer. The myriad of techniques preclude the recommendation of a standard approach to esophageal resection. We investigate the difference in outcomes between the trans-thoracic (TT) and trans-hiatal (TH) approach in esophageal cancer patients undergoing esophagectomy.
Methods: A prospectively managed esophagectomy database was queried for patients undergoing trans-thoracic or trans-hiatal esophagectomy between 1996 and 2015. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded. 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. All statistical tests were two-sided and an α (type I) error <0.05 was considered statistically significant.
Results: We identified 846 patients who underwent esophageactomy with a mean age of 64 ± 10 years, 714 (84.4%) TT and 132 (15.6%) TH. There were 239 (33.5%) patients within TT that underwent minimally invasive approach (MIE) and 63 (47.7%) within TH that underwent MIE. Post-operative complications occurred in 207 (29.0%) patients in the TT and 59 (44.7%) in the patients who underwent TH p<0.001. The most common complications in TT vs TH were anastomotic leak: 4.3% vs 9.8% p=0.01; anastomotic stricture 7% vs 26.5%, p<0.001; pneumonia 12.6% vs 22.7% p<0.002; aspiration 1.7% vs 15.9%, p<0.001; wound infection 4.5% vs 10.6% p=0.004; atrial fibrillation 13.6% vs 14.4%, p=0.8; and pleural effusion 3.2% vs 11.4%, p<0.001. There were 13 (1.5%) mortalities, 11 (1.5%) in the TT and 2 (1.5%) in the TH cohort, p=1. Neoadjuvant therapy was administered in 459 (64.3%) TT and 78 (59.1%) TH patients, p=0.2. R0 resections were comparable amongst groups 679 (95.6%) in TT and 122 (93.1%) in TH p=0.2. However the lymph node harvest was higher in the TT patients 12±8 compared to 9±6 in the TH group, p<0.001 and 18±9 in the MIE TT vs 9±6 in the MIE TH, p=0.001.
Conclusion: While both TT and TH are acceptable techniques for esophageal resection, the trans-thoracic approach is associated with fewer post-operative complications. Pulmonary complications which are traditionally believed to be lower in the TH groups were also higher in patients undergoing the trans-hiatal approach. Additionally, patients undergoing TT demonstrated superior nodal harvest which may have implications in oncologic outcomes.