Outcomes after transhiatal and transthoracic esophagectomy for cancer

Background. Although single-center series evaluating esophagectomy for cancer have demonstrated that this operation can be performed safely and with excellent outcomes, controversy remains regarding the comparable oncologic efficacy of the transhiatal and transthoracic approaches. This study was performed to determine outcomes after transhiatal and transthoracic esophagectomy for patients undergoing resection nationwide. Methods. Using the Surveillance, Epidemiology, and End Results -Medicare linked database (1992 to 2002), we identified registered patients undergoing esophagectomy for esophageal cancer. We evaluated operative mortality, late survival, and length of stay while adjusting for patient characteristics, tumor grade, and stage. As a surrogate for postoperative quality of life, we also assessed subsequent need for anastomotic dilation. Results. Of 868 patients undergoing either approach, for whom distinct Current Procedural Technology codes could be identified, 225 underwent transhiatal and 643 received transthoracic esophagectomy. Lower operative mortality rate was observed after a transhiatal than transthoracic approach (6.7% versus 13.1%, p = 0.009). Observed 5-year survival was higher for patients undergoing transhiatal rather than transthoracic esophagectomy (30.5% versus 22.7%, p = 0.02). After adjusting for differences in tumor stage, patient, and provider factors, this survival advantage was no longer statistically significant (adjusted hazard ratio for mortality, 0.95, 95% confidence interval: 0.75 to 1.20). Patients undergoing transhiatal esophagectomy were more likely to require endoscopic dilatation within 6 months of surgery (43.1% versus 34.5% for transthoracic operations, p = 0.02). Conclusions. In the largest population-based study to date assessing long-term outcome after esophagectomy for esophageal cancer, transhiatal esophagectomy confers an early survival advantage, but long-term survival does not appear to differ according to surgical approach.