Indicators of prognosis after transhiatal esophageal resection without thoracotomy for cancer

Indicators of Prognosis after Transhiatal EsophagealResection Without Thoracotomy for CancerJohanna W van Sandick, MD, J Jan B van Lanschot, MD, Fiebo JW ten Kate, MD, Jan GP Tijssen, MD,Hugo Obertop, MD

BACKGROUND: Various techniques have been described for the surgical treatment of esophageal cancer. Thetranshiatal approach has been debated for its safety and oncologic results.

STUDY DESIGN: Between January 1993 and September 1996, 115 patients underwent a transhiatal esophagec-tomy with curative intent for adenocarcinoma or squamous cell carcinoma of the middle ordistal esophagus or esophagogastric junction. Procedure-related hazards, pathologic results, andprognostic factors for survival were evaluated. Median duration of postoperative followup was27 months (range 1 to 74 months) for all patients and 45 months (range 30 to 74 months) forthose alive at final followup.

RESULTS: No emergency thoracotomies were experienced. In-hospital mortality was 3.5%. Vocal corddysfunction (24%) and pulmonary complications (23%) were the most frequent early postop-erative complications. A microscopically radical resection was achieved in 73% of patients.Overall survival was 45% at 3 years. In univariate analysis, the most pronounced indicators oflongterm survival (p�0.0001) were radicality of the resection, lymph node involvement,lymph node ratio (ie, the ratio of invaded to removed lymph nodes), and pathologic tumorstage. Multivariate analysis identified the lymph node ratio (p�0.0001) as the strongest inde-pendent predictor of long-term survival, followed by radicality of the resection (p�0.0064)and duration of ICU stay (p�0.027).

CONCLUSIONS: Transhiatal esophagectomy without thoracotomy can be considered a safe procedure for resect-able cancer of the midesophagus, distal esophagus, or esophagogastric junction. Radicality andsurvival results were in line with the data reported for traditional transthoracic approaches. Aprognostic value of the lymph node ratio was observed. It emphasizes the need for controlledtrials aimed at delineating the prognostic impact of an extended lymph node dissection. (J AmColl Surg 2002;194:28–36. © 2002 by the American College of Surgeons)

Worldwide, different techniques have been advocatedfor surgical treatment of esophageal carcinoma.1 Forcancer of the intrathoracic esophagus immediately adja-cent to the distal trachea, careful dissection of the pri-

mary tumor can necessitate a transthoracic surgical ap-proach.2 Conversely, for tumors located at lower levels ofthe esophagus, the need to perform a thoracotomy iscontroversial.3 In our institution, transhiatal esophagec-tomy without thoracotomy is the treatment of choice forresectable cancer involving the middle or distal esopha-gus or esophagogastric junction (EGJ). Since its intro-duction,4 the transhiatal technique has been subject toample discussion. Opponents have underlined its higherintraoperative risks, a violation of radical oncologic sur-gery, and the dismal longterm survival rates.5-7 Propo-nents have claimed that avoidance of a thoracotomywould decrease postoperative morbidity without anynegative effect on longterm prognosis.8-10 To date, mostsurgeons adhere to a transthoracic resection as the pre-ferred method in esophageal cancer surgery, but in se-lected cases, the transhiatal technique is favored, eg, for

No competing interests declared.

Part of this work has been presented in a previous publication (Van SandickJW, Obertop H, Fockens P, et al. Transhiatale oesofagusresectie zonder tho-racotomie vanwege carcinom: complicaties, ziekenhuissterfte en prognose bij115 patienten. Ned Tijdschr Geneeskd 2000;144:2061–2066), with permis-sion.

Received March 28, 2001; Revised August 3, 2001; Accepted September 7,2001.From the Departments of Surgery (van Sandick, van Lanschot, Obertop),Pathology (ten Kate), and Clinical Epidemiology and Biostatistics (Tijssen),Academic Medical Center, University of Amsterdam, Amsterdam, TheNetherlands.Correspondence address: Johanna W van Sandick, MD, Department of Sur-gery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, TheNetherlands.

28© 2002 by the American College of Surgeons ISSN 1072-7515/02/$21.00Published by Elsevier Science Inc. PII S1072-7515(01)01119-X

patients with decreased physiologic reserve, or when pal-liation rather than cure is anticipated.3,6,11-13 As a result,unbiased evaluation of procedure-related treatment out-comes is often not possible. Encouraged by the contra-dictory attitudes concerning transhiatal esophageal re-section, we performed a study that aimed to investigatethe intraoperative hazards, the pathologic results, andshortterm and longterm clinical outcomes of transhiatalesophagectomy for cancer, using a uniform surgicaltechnique in a consecutive series of patients operated onduring a 31

2-year period. Potential prognostic factorswere evaluated to determine which parameters influencecure rates in esophageal cancer surgery.

METHODSStudy populationBetween January 1993 and September 1996, 208 pa-tients with adenocarcinoma or squamous cell carcinomaof the intrathoracic esophagus or EGJ were scheduledfor operations with curative intent (ie, locally resectabledisease and no distant metastases on preoperative evalu-ation). Patients who underwent transhiatal esophagec-tomy without thoracotomy for an untreated cancer ofthe middle or distal esophagus or EGJ were included inthe study (n�115). Ninety-three patients were ineligi-ble for this analysis because of neoadjuvant chemother-apy (n�19),14 randomized allocation to an extendedtransthoracic procedure (n�35),15 tumor involvementof the supracarinal esophagus (n�24), irresectable dis-ease on exploratory laparotomy (n�14), or incompletefollowup data (n�1). Supracarinal disease was obviouson preoperative examination in 13 patients, and wasfound during transhiatal surgical exploration in 11 pa-tients. Resectable high-thoracic tumors were treated bylimited transthoracic esophagectomy. The 115 study pa-tients had a median age of 65 years (range 37 to 83years). The male to female ratio was 4:1. Data werecollected from a prospective surgical database and byreview of original patient documents (eg, pathology re-ports).

Preoperative evaluationRoutine preoperative evaluation involved upper gastro-intestinal endoscopy with biopsy, endoscopic ultra-

sonography,16 external ultrasonography of the neck andupper abdomen (with fine needle aspiration of suspectedlesions), indirect laryngoscopy, and chest radiography. Ifairway involvement could be expected by the site of thetumor, local resectability was further evaluated by bron-choscopy. Diagnostic laparoscopy with laparoscopic ul-trasonography was performed mostly in patients withtumors involving the EGJ.17 Operative risk analysis in-cluded standard blood examination, electrocardiogra-phy, pulmonary function tests (if indicated), and anes-thesiologic consultation.

Surgical techniqueAll patients underwent subtotal esophagectomy andproximal gastrectomy by the transhiatal technique asdescribed in detail by Orringer.18 Our method of posi-tioning and draping has been reported.19 It enables aright-sided thoracotomy if necessary, without renewedpreparation of the operative field. After abdominal ex-ploration, retractors were routinely positioned in theesophageal hiatus to facilitate exposure of the intratho-racic esophagus up to the level of the carina. Care wastaken to identify extraesophageal tumor extension thatwould preclude safe transhiatal resection or restrict itscurative intent. Standard lymph node dissection in-volved lymph nodes in the lower mediastinum, aroundthe EGJ, and along the lesser curvature of the stomach(including those at the origin of the left gastric artery).When possible, en bloc removal of subcarinal lymphnodes was performed. Lymph nodes at the celiac trunkwere included when enlarged and resectable. Gastroin-testinal continuity was preferably reestablished with anarrow gastric tube vascularized by the right gastroepi-ploic artery (93%). In eight patients (7%) with previousgastric resection, the left colon was used for reconstruc-tion. The neoesophagus was most frequently positionedin the posterior mediastinum (98%). All anastomoseswere performed in the neck, almost invariably by a right-sided cervical incision. A surgical stapler was used (52%)or the anastomosis was handmade with a one-layer run-ning suture (48%). Insertion of chest tubes (usually bi-lateral) and placement of a feeding jejunostomy wereadded to the procedure in all patients.

Pathologic examinationSamples were routinely taken from the proximal anddistal resection margins, from longitudinal stripsthrough the primary tumor and adjacent tissue, andfrom all lymph nodes that were recognized as such. Tu-

Abbreviations

EGJ � esophagogastric junction

29Vol. 194, No. 1, January 2002 van Sandick et al Transhiatal Esophageal Resection Without Thoracotomy

mors were registered as esophageal or EGJ cancer basedon macroscopic tumor location, irrespective of the pres-ence of Barrett mucosa. Postsurgical staging was doneaccording to the revised pTNM-classification of esoph-ageal carcinoma.11,20

FollowupFor immediate postoperative observation, patients wereadmitted to the ICU, at least until the next day. Routineinvestigations during postoperative hospitalization in-cluded a water-soluble contrast swallow examination toexclude subclinical leakage of the cervical anastomosisand indirect laryngoscopy to evaluate vocal cord func-tion. After discharge, additional diagnostic procedureswere only performed if indicated. Patients were seen inthe outpatient clinic 3 weeks after discharge, at 3-monthintervals for 2 years, and at 6-month intervals thereafter.Median duration of postoperative followup was 27months (range 1 to 74 months) for all patients and 45months (range 30 to 74 months) for those alive at finalfollowup.

StatisticsAll data were analyzed using SPSS 7.5 for Windows 95(SPSS Inc, Chicago, IL). Survival was estimated accord-ing to the method of Kaplan and Meier, including allcauses of death unless stated otherwise. In univariateanalysis, the log-rank test was used for comparison ofsurvival curves. Statistical significance was defined asp�0.01. Independent prognostic factors for survivalwere determined by Cox’s proportional hazard regres-sion analysis in a forward stepwise manner. Enter limitand removal limit were p�0.05. The relative risk (with95% confidence interval) was used to quantify the rela-

tionship between survival time and each independentfactor.

RESULTSPreoperative featuresDysphagia was the main presenting symptom in 77 pa-tients (67%). Thirteen patients (11%) presented withretrosternal or epigastric pain, 6 patients (5%) with he-matemesis or melena, and 11 patients (10%) with othergastrointestinal symptoms. Eight patients (7%) had anasymptomatic cancer detected on routine surveillanceendoscopy for Barrett’s esophagus. Percentage weightloss during the year before operation was more than 5%in 54 patients (47%). According to the American Soci-ety of Anesthesiologists (ASA) classification,21 operativerisk was scored as ASA-I (n�22), ASA-II (n�65), orASA-III (n�28).

Intraoperative surgical findingsDuring the operation, there were no intrathoracic inju-ries necessitating emergency thoracotomy. Iatrogenic in-jury of the spleen requiring its resection occurred in 10patients (9%). At final removal of the surgical specimen,the esophagus was lacerated in six patients (5%). In themajority of patients (n�109; 95%), no macroscopictumor was left behind. Median duration of the proce-dure was 4.0 hours (range 2 to 8 hours), and medianintraoperative blood loss was 1,000 mL (range 250 to5,500 mL).

Postoperative courseThe 30-day mortality rate was 0.9% (one patient). In-hospital mortality was 3.5% (four patients). The inci-dence of early postoperative complications is summa-

Table 1. Early Postoperative Complications in 115 Patients Who Underwent Transhiatal Esophagectomy for CancerPostoperative complications n %

Vocal cord dysfunction* 28 24Pulmonary complications 27 23Cardiac complications 15 13Reoperation (relaparotomy, thoracotomy, or both) 12 10Cervical anastomotic leakage† 10 9Sepsis or systemic inflammatory response syndrome 10 9Wound infection 7 6Mediastinitis/necrotic gastric tube 2 2Chylothorax‡ 2 2At least one of the listed complications 61 53

* Vocal cord dysfunction was transient in 20 of 28 patients.† Anastomotic leakage was subclinical (only radiologic) in 2 patients and clinically manifest (salivary fistula) in 8 patients.‡ In both patients with a chylothorax, the condition was managed conservatively.

30 van Sandick et al Transhiatal Esophageal Resection Without Thoracotomy J Am Coll Surg

rized in Table 1. Indications for surgical reintervention(relaparotomy, thoracotomy, or both) were clinical leak-age of the cervical anastomosis (n�1), transhiatal her-niation of colon (n�1), intestinal herniation aroundthe jejunal fistula (n�1), dehiscence of abdominal wallfascia (n�1), gastric tube necrosis (n�2), bleeding inthe esophageal bed (n�2), and abdominal sepsis (n�4). Most anastomotic leakages (8 of 10) healed sponta-neously by postponement of oral feeding (one patientwith clinical leakage died postoperatively). Median du-ration of mechanical ventilation was 1 day (range 0 to 33days). ICU stay varied from 1 day to 36 days (median 3days), and postoperative hospital stay varied from 10 to113 days (median 16 days). Benign anastomotic stenosisoccurred in 46 patients (40%) after a median followupof 2 months (range 1 to 20 months). Strictures weretreated by (repeated) endoscopic dilatation in 1 to 30sessions (median 6 sessions).

Histopathologic findingsHistologic tumor type was adenocarcinoma in 86 pa-tients (75%) and squamous cell carcinoma in 29 pa-tients (25%). By location, there were 51 EGJ tumors(44%), 45 distal esophageal tumors (39%), and 19midesophageal tumors (17%). The tumor was well dif-ferentiated (n�10), moderately differentiated (n�39),or poorly differentiated (n�66). Depth of tumor infil-tration, frequency of nodal metastasis, and radicality ofthe resection are shown in Table 2. The median numberof lymph nodes in the resection specimens was 12 (range1 to 40). In patients with lymph node metastasis, theratio of invaded to removed lymph nodes (lymph noderatio) varied from 0.03 to 1.0 (median 0.3). Nodal me-tastasis was restricted to regional areas in 43 patients; 20patients had celiac lymph node involvement and onepatient had cervical lymph node involvement. Patho-logic stage distribution was 16% (n�18) stage I, 27%

(n�31) stage IIA, 6% (n�7) stage IIB, 33% (n�38)stage III, and 18% (n�21) stage IV.

Tumor recurrence and survivalTumor recurrence was detected in 64 patients (56%).Recurrent disease was locoregional (n�22), systematic(n�22), or both (n�20). Most recurrences (88%) weredetected within 2 years after surgery. At last evaluation,61 patients with recurrent disease had died (being thecause of death in all but one who died of postoperativecomplications). Other causes of death (n�3) were lungcancer, cerebrovascular disease, and progressive Parkin-son’s disease. Forty-eight patients were alive and all buttwo were without evidence of tumor recurrence (onepatient had a solitary lung metastasis resected with cur-ative intent). Overall survival was 72% at 1 year, 53% at2 years, and 45% at 3 years (Fig. 1).

Potential indicators of longterm survival were assessedin patients who survived the postoperative period in thehospital (n�111). In univariate survival analysis, the mostimportant prognostic factors were radicality of the resec-tion, lymph node involvement, lymph node ratio (Fig. 2),and pathologic stage of disease (all p�0.0001; Table 3). Ina multiple stepwise regression analysis, the final modelidentified the lymph node ratio as the strongest indepen-dent predictor of longterm survival, followed by radical-ity of the resection and duration of ICU stay (Table 4A).When only patients with less than 15 identified lymphnodes were entered in the Cox model, the conventionalnodal status was the most significant independent prog-nostic factor (Table 4B); in patients with at least 15identified lymph nodes, the lymph node ratio persistedas an independent prognostic factor (Table 4C).

DISCUSSIONThe first transhiatal esophageal resection without thora-cotomy was reported by Grey Turner in 1933.4 Only

Table 2. Lymph Node Involvement and Radicality of the Resection According to Depth of Tumor Infiltration

Depth of tumorinfiltration

Lymph nodeinvolvement

Radicality of resection

R0 R1 R2

n n % n % n % n %

pT1* 24 6 25 24 100 0 0 0 0pT2 5 2 40 5 100 0 0 0 0pT3 75 47 63 48 64 22 29 5 7pT4 11 9 82 7 64 3 27 1 9Total 115 64 56 84 73 25 22 6 5

* pT1 includes pT1a (0/8�0% nodal metastasis) and pT1b (6 /16�38% nodal metastasis). R0, microscopically radical resection; R1, microscopically irradicalresection; R2, macroscopically irradical resection.


since its reintroduction by Orringer and Sloan,22 in1978, has there been an increase in the use of transhiatalesophagectomy. More than two decades have passed andthis technique for surgical treatment of esophageal can-cer is still controversial. Its safety and potential for curewere evaluated in a consecutive series of 115 patientswho underwent transhiatal esophagectomy for an un-treated cancer of the midesophagus, distal esophagus, orEGJ. Tumor histology was either adenocarcinoma orsquamous cell carcinoma, and all patients had poten-tially curable disease based on preoperative investiga-tions. No emergency thoracotomies were experienced.In-hospital mortality was 3.5% and overall 3-year sur-vival 45%.

One of the main concerns of transhiatal esophagec-tomy has been the risk of massive mediastinal bleedingnecessitating conversion to a transthoracic procedure. Ithas been reported to occur in about 1% of patients.2,10

Tracheal injury has an incidence of less than 1%. Epi-sodes of intraoperative hypotension have been docu-mented during transhiatal exploration of the posterior

mediastinum and have led some authors to question thesafety of this approach as opposed to a transthoracictechnique, although an increase in cardiac or any otheradverse events was not observed.23 The present data in-dicate that the transhiatal method can be considered asafe procedure in esophageal cancer surgery for tumorsthat do not extend proximal to the carina. Placement ofretractors in the esophageal hiatus enables intramedias-tinal exploration under direct vision up to the level of thecarina.24 The supracarinal intrathoracic esophagus ispartially visualized through the cervical incision, but itleaves a blind area directly posterior to the distal tracheaand its bifurcation.18 It is at this level that injuries to theazygos vein and lacerations of the membraneous tracheahave been reported. Patients with tumors involving theupper intrathoracic esophagus are particularly prone tothe reported hazards of blind dissection. In our hospital,these patients are not considered candidates for transhi-atal resection. Preoperative esophagoscopy or esopha-gography might already demonstrate supracarinal tumorinvolvement. Other diagnostic modalities (endoscopic

Figure 1. Overall survival in 115 patients who underwent transhiatal esophagectomy for cancer of the esophagus or esophagogastric junction(including in-hospital mortality), as calculated by the Kaplan-Meier method. The numbers in the box refer to the number of patients at risk at12-month intervals.


ultrasonography, CT scan, bronchoscopy) also providecritical information about the feasibility of transhiatalesophagectomy. A final guide to safe transhiatal resec-tion is the progress of blunt dissection in the upper me-diastinum. If mediastinal attachments to adjacent struc-tures cannot be separated easily, a low threshold fordifficulty as an indication for converting to a transtho-racic procedure is recommended.2

Comparing historical figures with recent figures,postoperative mortality of esophagectomy has obviouslydecreased. Earlam and Cunha-Melo25 reported a meanhospital mortality rate from the 1950s to 1970s of 29%,which declined to 13% in the 1980s, as reviewed byMuller and coworkers.26 Most studies since 1990 haveshown mortality rates below 10%,7-9,11,27 and some evenbelow 5%,10,28,29 which is in line with the rate of 3.5% inthe present series. It is most likely that this marked re-duction in hospital mortality results mainly from generalimprovements in patient care, in addition to an overallgrowing experience with esophageal cancer surgery. Re-

cent reports have demonstrated the impact of a singleinstitution’s experience, ie, postoperative mortality ratesvaried with the hospital’s volume of esophagectomies(3% to 5% in high-volume hospitals, compared with17% to 19% in low-volume hospitals).30,31 Obviously,these data should be interpreted with caution (eg, thereports did not adjust for readmission rates or transferralto other facilities); they nevertheless harbor a potentialentry to maximize the outcomes of esophageal cancersurgery.

Postoperative morbidity rates of esophagectomy con-tinue to be important. Theoretically, these might be re-duced by the avoidance of a thoracotomy. But with fewexceptions,8,9 comparative studies have failed to demon-strate less morbidity or shorter hospital stay with thetranshiatal technique.6,23,27,29,32 Pulmonary complica-tions and vocal cord dysfunction were the most commoncomplications in our study, which is in parallel with thefindings of other authors.2,6,26,27 Although usually tran-sient, vocal cord dysfunction increases the risk of pulmo-

Figure 2. Survival according to the lymph node ratio (LNR) after transhiatal esophagectomy for cancer of the esophagus or esophagogastricjunction (excluding in-hospital mortality), as calculated by the Kaplan-Meier method and log-rank test (p�0.0001). The numbers in the boxrefer to the number of patients at risk at 12-month intervals.


nary complications.33 Dedicated physiotherapy, early ex-tubation, and the use of epidural anesthesia help tominimize the incidence of marked pulmonary compro-mise.10 In gastric cancer, an independent prognostic im-pact of postoperative complications on longterm sur-vival has been demonstrated.34 Similarly, we found that

longterm prognosis after esophagectomy was indepen-dently affected by the duration of ICU stay. It can behypothesized that a prolonged postoperative course canadversely affect immunologic resistance to residual tu-mor cells, but such mechanisms await further investiga-tions.

Table 3. Clinical and Pathologic Features Related to Survival after Transhiatal Esophagectomy for Cancer (n�111)Parameter Category* p Value (log-rank)

Preoperative dysphagia No; yes 0.0020Weight loss (% in previous year) 0-5%; �5% 0.0016Postoperative sepsis or SIRS Absent; present 0.0016Duration of ICU stay (d) �3; 4–10; �10 0.0005Postoperative hospital stay (d) �16; 17–30; �30 0.0056Tumor differentiation Well; moderate; poor 0.0092Radicality of resection† R0; R1; R2 �0.0001Depth of invasion (pT) pT1; pT2; pT3; pT4 0.0004Lymph node metastasis (pN) pN0; pN1 �0.0001Distant lymph node metastasis (pM) pM0; pM1 0.0004Lymph node ratio (LNR)‡ pN0; LNR�0.30; LNR�0.30 �0.0001Pathologic stage (pTNM) I; IIA; IIB; III; IV �0.0001

Data exclude in-hospital deaths (n�4). Variables that demonstrated no correlation with longterm survival were age, gender, American Society of Anesthesiol-ogists classification, duration of operation, peroperative blood loss, splenectomy, duration of ventilation, vocal cord dysfunction, pulmonary complications,cardiac complications, reoperation, cervical anastomotic leakage, tumor location, tumor histology, and the extent of lymph node dissection (ie, the number oflymph nodes harvested). Actual univariate p values were �0.025 for these variables.* Categories are listed in a sequence of decreasing survival times.† R0 versus R1, p�0.0044; R1 versus R2, p�0.016.‡ pN0 versus LNR�0.30, p�0.0009; LNR�0.30 versus LNR�0.30, p�0.0027.SIRS, systemic inflammatory response syndrome.

Table 4. Ranking of Independent Prognostic Factors for Survival after Transhiatal Esophagectomy for Cancer(Excluding In-Hospital Mortality)

Prognostic factorHazard ratio

(95% confidence interval)p Value

(multivariate)

A. In all patients (n�111)Lymph node ratio (LNR) pN0 1 �0.0001

LNR�0.30 3.1 (1.6–6.1)LNR�0.30 5.8 (3.0–11.4)

Radicality of resection R0 1 0.0064R1 1.8 (1.0–3.1)R2 4.2 (1.6–10.9)

Duration of ICU stay (d) �3 1 0.0274–10 1.3 (0.7–2.2)�10 2.9 (1.3–6.2)

B. In patients with�15 lymph nodes identified (n�64)Lymph node metastasis (pN) pN0 1 �0.0001

pN1 4.8 (2.4–9.9)Radicality of resection R0 1 0.0019

R1/2 3.0 (1.5–6.0)C. In patients with�15 lymph nodes identified (n�47)Lymph node ratio (LNR) pN0 1 �0.0001

LNR�0.30 4.6 (1.3–16.5)LNR�0.30 19.2 (4.9–75.2)


As in previous multivariate analyses,6,35 radical clear-ance of the primary tumor (R0 resection) emerged asone of the most important parameters determininglongterm survival in patients with resected cancer of theesophagus or EGJ. Advocates of a transthoracic ap-proach have suggested that the transhiatal procedurewould limit the yield of tumor-negative dissection mar-gins, violating basic principles of oncologic surgery. Inthe present series, a curative resection in terms of tumor-free surgical margins was achieved in 73% of patients.This figure is similar to those reported for transthoracicesophagectomy.6,35,36 Randomized data comparing theyield of R0 resections by the transhiatal versus the trans-thoracic approach are not available.

Another subject of concern with transhiatal esopha-gectomy has been claimed by advocates of extendedlymph node dissections.1,7,35,37 Undoubtedly, a formallymphadenectomy improves the accuracy of postopera-tive staging, which is thereby a result of both the surgicalprocedure and the pathologist’s search for lymph nodesin the resection specimen. The minimum number oflymph nodes to be submitted to the pathologist for acorrect pathologic staging has long been a matter ofdiscussion. In 1995,38 a panel of experts suggested thatresection of a subcarinal cancer should include at least 15lymph nodes, derived from both the abdomen and themediastinum, to achieve an accurate pathologic staging.So, we performed a separate multivariate analysis forpatients with at least 15 identified lymph nodes. Thisanalysis revealed that detailed lymph node staging canprovide exclusive prognostic information. Alternatively,extended lymphadenectomy might not only be seen as astaging procedure. Its therapeutic rationale would be theremoval of micrometastatic disease. There are some re-ports indicating that patient survival might benefit fromextended lymph node dissection,3,6,37 but available dataare contradictory.12,26,29 In our series, the extent of thelymph node dissection was not a major prognostic fac-tor. Interestingly, the ratio of invaded to removed lymphnodes was documented as an important predictor of sur-vival. One can argue that this finding provides an argumentin favor of an extended lymph node dissection.35 It is thenbelieved that the resection of lymph nodes with microme-tastases markedly improves longterm survival. Data to sub-stantiate this view have been reported, although other stud-ies were not confirmatory.39 A controlled clinical trial is thepreferred method to elucidate the prognostic significance ofan extended lymph node dissection.

Longterm survival rates from different surgical seriesare difficult to compare because of wide variations indata collection, preoperative staging measures, patientinclusion, and survival calculations. In most series re-ported after 1990,9,13,28,29,35 overall survival rates afterresection were between 35% and 55% at 2 years (53% inthe present study) and between 15% and 35% at 5 years.In general, current survival figures compare favorablywith those collected by Earlam and associates25 (29%2-year and 18% 5-year survival) and by Muller and co-workers26 (34% 2-year and 20% 5-year survival). Theimprovements made largely originate from the reduc-tion in operative mortality. Beyond this effect, longtermprognosis has not substantially changed over the pastfew decades. In view of the often-made suggestion thatthe transthoracic approach provides a beneficial impacton longterm survival, it should be emphasized that ran-domized data, although restricted to small series of pa-tients, do not support this assumption.23,27,32,40 Results ofnonrandomized studies might be affected by historicalbias, staging differences, and selective indications for theadopted surgical techniques. A common approach is toregard (extended) transthoracic esophagectomy as thestandard surgical procedure, reserving the transhiataltechnique for patients who would not tolerate athoracotomy.3,6,11-13 Also, a selective surgical approachbased on preoperative staging results has been reported,advocating that the transhiatal technique would only beappropriate for early tumors or, conversely, for locallyadvanced disease.3,5,6,28

We have shown that transhiatal esophagectomy with-out thoracotomy can be considered a safe procedure forresectable cancer of the esophagus or EGJ, provided thatthe esophageal tumor does not extend proximal to thecarina. Radical resections, postoperative complicationrates, and survival results were in line with data reportedfor traditional transthoracic approaches. In our hospital,the transhiatal approach continues to be the method ofchoice while awaiting longterm results of a randomizedstudy comparing transhiatal esophagectomy versustransthoracic esophagectomy with two-field lymphnode dissection.15

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Indicators of prognosis after transhiatal esophageal resection without thoracotomy for cancer