Asian Cardiovasc Thorac Ann 2000;8:347-352
© 2000 Asia Publishing EXchange Pte Ltd
Transhiatal Versus Transthoracic Esophagectomy for Distal Esophageal Cancer
Narendar Mohan Gupta, MS
Department of Surgery
Postgraduate Institute of Medical Education and Research
Chandigarh, India
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For reprint information contact: Narendar Mohan Gupta, MS Tel: 91 172 71 5071 Fax: 91 172 74 4401 email: medinst{at}pgi.chd.nic.in Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Abstract
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From 1982 to 1986, 27 of 34 consecutive patients with squamous cell carcinoma of the distal esophagus had resection by the transthoracic approach. From 1987 to 1990, 39 of 48 consecutive patients underwent transhiatal esophagectomy. The two groups were comparable in terms of demographics, preoperative risk factors, and tumor stage. All patients had received one cycle of anterior chemotherapy. The incidence of pneumonia and wound infection was significantly higher following transthoracic compared to transhiatal resection (44% versus 18%). Transhiatal esophagectomy required markedly less operating time (137 versus 327 min) but had a higher incidence of recurrent laryngeal nerve palsy (20% versus 0%). Anastomotic leaks occurred with similar frequency in both groups (23% versus 19%) and intrathoracic disruption carried a very high mortality (80%). Transhiatal resection had lower mortality (10% versus 26%) and both groups had similar survival. These results suggest that compared to transthoracic esophagectomy, the transhiatal approach had fewer complications, a lower mortality rate, and comparable survival, and thus remains an acceptable procedure for resection of squamous cell carcinoma of the distal esophagus.
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Introduction
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Carcinoma of the esophagus is a devastating disease as it carries significant morbidity and mortality. It is generally accepted that one-stage surgical resection and re-construction by esophagogastrostomy remains the best modality for palliation without compromising the potential for cure in some cases. However, the preferred approach for resection is controversial and varies with the individual surgeon. The conventional operation, in which the esophagus and adjacent lymph nodes are dissected under vision through the right chest with intrathoracic esopha-gogastric anastomosis, is preferred by most surgeons.1 The procedure of transhiatal (TH) esophagectomy with cervical esophagogastrostomy popularized by Orringer2 has gained widespread acceptance. It avoids thoracotomy and the esophagectomy performed is subtotal.
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Patients and Methods
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Between August 1982 and September 1986, 27 of 34 consecutive and unselected patients with squamous cell carcinoma of the lower third of the esophagus and gastroesophageal junction were subjected to surgery with the intent of performing esophagectomy (Tanner and Lewis) with intrathoracic esophagogastric anastomosis. No patient was denied exploration because of a locally extensive lesion or associated diseases, provided he or she was fit for surgery. The details of these patients are given in Table 1
. However, when the data were analyzed at the end of 1986, the operative mortality was found to be 26% which was higher than the reported 5-year survival for esophageal carcinoma. Hence, in December 1986, the author abandoned the transthoracic (TT) approach and resorted to TH esophagectomy. Between December 1986 and February 1990, 39 of 48 consecutive and unselected patients with squamous cell carcinoma of lower esophagus and gastroesophageal junction were surgically treated by this approach. The details of these patients are also given in Table 1.
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Table 1. Characteristics and Tumor Stage in Patients Undergoing Transhiatal or Transthoracic Esophageal Resection
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All patients were subjected to preoperative evaluation that included a thorough clinical examination and cardiopulmonary assessment. The degree of dysphagia was graded: grade I, the patient could swallow solids but with difficulty; grade II, only semisolids could be swallowed; grade III, only liquids could be swallowed; and grade IV, nothing could be swallowed (absolute dysphagia). The tumor was assessed by barium swallow and flexible endoscope. Tumors distal to 30 cm were included in the study. The involvement of the fundus of the stomach was noted on contrast esophagograms and endoscopy, provided the endoscope could be negotiated past the tumor. Blood was tested for hemogram, renal and liver function tests. Chest radiography and ultrasound scanning of the abdomen were also carried out.
All patients were given one cycle of anterior polydrug chemotherapy consisting of: (1) cisplatin 80 mg•m–2 by intravenous infusion in divided dosages over a period of 1 day, (2) bleomycin 30 mg intravenous bolus on day 1, and (3) mitomycin 10 mg intravenous bolus on day 1. Four weeks after chemotherapy, the patients were readmitted for surgery and the tumor was reassessed by thorough clinical examination, barium esophagogram, and esophagogastroduodenoscopy. Pulmonary function tests were performed regularly, however, computed tomography was not often undertaken.
The diagnosis of squamous cell carcinoma was confirmed in all patients by endoscopic biopsy or brush cytology. Five cases were excluded from the study when the final diagnosis of the resected specimens was adenocarcinoma (2 in the TT group and 3 in the TH group). A decision on surgery was made on clinical assessment. Age and cachexia were not contraindications to surgery, but the presence of a tracheoesophageal fistula was an absolute contrain-dication. Patients with Karnofsky performance status of less than 50% (confined to bed for most of the time) were also not subjected to surgery. Patients with solitary metastatic deposits in the liver were operated upon, provided they were fit for surgery. Preoperative manage-ment included correction of anemia, dehydration, and biochemical deficiencies. Patients with inadequate oral intake were treated by nasogastric tube feeding or feeding jejunostomy. Vigorous chest physiotherapy was initiated in all cases and continued in the postoperative period.
Both procedures (TT and TH) were carried out in the standard manner. TT esophagectomy was performed as described by Lewis3 and Tanner4 through the right chest and abdomen. Esophagogastric anastomosis was carried out at the level of the azygos vein in two layers, the inner with continuous 2/0 polyglactin (Vicryl; Ethicon Division of Johnson and Johnson Ltd., Aurangabad, Bihar, India) and the outer with interrupted silk sutures. The technique of TH esophagectomy was essentially as reported by Orringer and Sloan.5
Postoperative care was the same after both operative procedures. Patients were not routinely ventilated unless indicated, and extubation on completion of the operation was the rule. After initial observation in the recovery room, patients were moved back to the wards. Expansion of the lungs was confirmed by chest radiography, and oxygenation by arterial gas analysis. Tube feeding was started on the second postoperative day. Oral feeds were started 5 to 7 days later after confirming the integrity of the anastomosis by water-soluble contrast radiography. If a leak was detected, oral feeds were withheld and tube feeding was continued. After discharge, patients were followed up in the outpatient department. Development of dysphagia was indicative of anastomotic stricture; if confirmed by endoscopy, it was treated by endoscopic dilatation.
Resected specimens of the esophagus were examined histopathologically and subjected to surgical staging based on the American Joint Committee on Cancer in conjunction with the International Union Against Cancer classification, using the tumor-node-metastasis format.6 Statistical analyses were performed using Student's t test and the chi-squared test for comparison of 2 groups. Actuarial survival curves were constructed using the Kaplan-Meier method.
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Results
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No differences were noted between the TH and TT groups in terms of mean age, gender, degree of dysphagia, associated diseases, or histopathological staging of the resected tumors (Table 1
). In both groups, most of the patients had advanced disease. Three patients (6%) in the TH group were older than 70 years compared to 1 (3%) in the TT group. Preoperative respiratory assessment revealed that 5 patients in the TH group had chronic obstructive pulmonary diseases and increased surgical risk, compared to none in the TT group. Two patients in the TH group had forced expiratory volumes in 1 second of only 1.1 L and 0.9 L.
No major side effects of chemotherapy were noticed in any patient. No dosage modifications were necessary. Three patients (2 in the TT group and 1 in the TH group) developed myelosuppression as evidenced by leukopenia and thrombocytopenia, which recovered spontaneously. One patient in the TT group developed a high serum creatinine level (25 mg•L–1) that returned to normal after hydration.
The resectability rates of the tumors were similar in both groups (Table 1). Overall hospital morbidity and mortality for each group can be seen in Table 2. Specific intra-operative complications from TH resection included transitory hypotension during manipulation in the media-stinum, recurrent laryngeal nerve injury, bleeding (n = 1) and tumor rupture (n = 2). Significant complications in the TT group were pneumonia, wound infection, and longer operating time. Absence of recurrent laryngeal nerve palsy was the distinct advantage of this procedure.
TT resection took more than twice the time to complete compared to TH resection (Table 2). The mean blood transfusion requirements for the TH and TT groups were not significantly different at 2.1 (range, 1 to 5) versus 2.8 (range, 2 to 6) units. Two patients undergoing TH resection had a splenectomy after iatrogenic trauma to the spleen by the retractor. Perforation of the tumor occurred in 3 patients. In those subjected to thoracotomy, splenectomy for injury was needed in 1 patient and there was no incidence of tumor perforation.
Anastomotic leakage was common in both groups. The incidence was slightly greater in the TH than the TT group. Following TH resection and cervical esopha-gogastric anastomosis, most leaks were minor and resolved spontaneously in 7 to 20 days and no mortality could be attributed to a leak. However, in the TT group, 4/5 patients (80%) died following an intrathoracic anastomotic leak. One patient was reexplored and the anastomosis was refashioned. All of these patients had developed empyema that required drainage. Thoracic duct injury and Horner's syndrome were not observed in any patient.
Hospital mortality was defined as any death during hospitalization or within 30 days of operation. Mortality for TH resection was less than half that of TT resection (Table 2). Intrathoracic anastomotic leakage and pneu-monia were the most common causes of death. Overall survival rates (Kaplan-Meier) for the TH and TT groups were 51% and 56% at one year, 26% and 30% at 2 years, and 8% and 11% at 5 years (Figure 1); the differences were not statistically significant. The majority of patients in both groups died within 6 to 12 months following surgery. After 7 years, 3 patients in each group were still alive. Three patients (2 in the TT group and 1 in the TH group) have survived for longer than 10 years. Due to the limited number of patients, no attempt was made to correlate survival to the stage of the disease.
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Figure 1. Actuarial survival of patients with squamous cell carcinoma of the distal esophagus resected through a transhiatal or transthoracic approach.
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Discussion
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All but one study comparing these 2 procedures have been retrospective, nonrandomized, and heterogenous.7 Even the indications for surgical approach were dissimilar, as patients who were old and at high cardiopulmonary risk were subjected to TH esophagectomy. This study, although retrospective and nonrandomized, compared similar groups of patients studied in an identical manner (Table 1). All patients had squamous cell carcinoma of the lower esophagus or cardia and were operated upon by the same surgeon in the same hospital.
The most common complication of esophagectomy without thoracotomy (TH) is recurrent laryngeal nerve palsy that is transient in most cases. Vocal cord palsy and dissection in the region of the trachea prevent adequate coughing, resulting in impaired pulmonary function post-operatively. However, in a collective review of the last decade, Muller and colleagues8 reported that the incidence of respiratory insufficiency and atelectasis was signifi-cantly higher following TT rather than TH esophagectomy (27% versus 13%, and 23% versus 10%, respectively). Similar observations were made in other studies.9–12 In this series, pulmonary complications were also more frequent following TT esophagectomy (51% versus 18%). On the other hand, some studies found no differences but these were mostly in patients who were selected; older individuals with cardiac and respiratory problems were subjected to the TH approach.7,13–16 The incidence has been found to be similar in some specialized centers.7 The increased incidence of pulmonary complications following TT esophagectomy could be attributed to the addition of thoracotomy in patients who were nutritionally depleted due to dysphagia.17 Pulmonary complications continue to be a major cause of mortality after esopha-gectomy.8,18
Another cause of pulmonary complications and deaths is leakage of the intrathoracic anastomosis. In a collective review by Muller and colleagues,8 anastomotic leaks were significantly more prevalent with cervical anastomoses (19% versus 11%), but mortality was significantly less (20% versus 69%). Similar figures have been reported more recently.11,12,15,19 No difference in leakage rate has been reported by others.10,14,20,21 Our incidence of anastomotic leak following TH resection and cervical anastomosis was 23%, but no death could be attributed to it. However, 4/5 patients died following an intrathoracic leak. Mortality after TH esophagectomy was less (10% versus 26%) although it did not reach statistical significance.
Operating time was significantly longer for TT resection as expected, because laparotomy and thoracotomy are performed in sequence and time is needed to reposition, reprepare, and drape the patient for thoracotomy.10,19 Some of the delay was unwarranted but inherent in the func-tioning of our operating theaters. For the TH approach, laparotomy and neck exploration are undertaken simul-taneously. However, longer operating time does not appear to have an adverse effect on the outcome. In this study, the incidence of wound infection was significantly higher following a TT approach. This could be due to the poor nutritional status of the patients. Pac and colleagues10 also reported a significantly higher incidence of wound infection after TT compared to TH resection (21% versus 10%).
TH esophagectomy also helps in reducing the incidence of tumor recurrence at the anastomotic site. The lymphatic drainage of the esophagus is not segmental but longitudinal via an extensive submucosal lymphatic plexus and longi-tudinal clearance of squamous cell carcinoma cannot be achieved unless 10 to 12 cm of the proximal esophagus is excised along with the tumor.22 This clearance may not be possible with a TT approach, especially for tumors of the middle third. Pac and colleagues10 reported 14% tumor recurrence following a TT resection compared to 2% after TH esophagectomy. Our incidence of recurrence was much less as all patients had lower esophageal tumors.
There was no difference in survival between the 2 groups and it has been observed by others that survival of esophageal carcinoma is stage specific and not operation specific; patients in the early stage of the disease consistently do better than those with advanced disease, regardless of the type of operation performed.12,23 The optimal treatment for carcinoma of the esophagus should aim at a cure or at least prolonged palliation. Quick and lasting relief from dysphagia is the primary goal of all such operations so that the patient can live and even die with dignity. This goal should be attained with the lowest possible morbidity and mortality (less than 10%). From this study, it was concluded that the TH approach has lower morbidity and mortality, and survival comparable with TT esophagectomy. The author has continued to perform this procedure for esophageal carcinoma for the last 11 years with satisfactory results.24
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References
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Abstract
Introduction
