Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients

BACKGROUND: Debate continues over whether transhiatal esophagectomy (THE) offers decreased morbidity and mortality compared with transthoracic esophagectomy (TTE). To definitively answer this question, we used the Nationwide Inpatient Sample database to compare morbidity and mortality after THE and TTE. STUDY DESIGN: Using ICD-9 procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing THE and TTE. Multivariate statistical analysis was completed to compare morbidity, mortality, length of stay, and hospital volume analysis between the groups. RESULTS: Between 1999 and 2003, 17,395 patients included in the Nationwide Inpatient Sample underwent esophagectomy. Mean patient age was similar in those undergoing THE and TTE (61.9 versus 62.0 years, respectively). Overall morbidity and mortality after esophagectomy were 50.7% and 8.8%, respectively. In-hospital mortality after THE was 8.91% compared with 8.47% after TTE (p = 0.642). Multivariate regression analysis showed no difference in the incidence of mediastinitis, wound, infectious, pulmonary, gastrointestinal, cardiovascular, systemic, procedure-related, or overall complications or hospital length of stay between the two groups. Controlling additionally for hospital volume showed high-volume centers (more than 10 esophagectomies per year) had significantly lower mortality rates than low-volume centers (10 or fewer esophagectomies per year, p = 0.024). Additionally, low-volume centers have a higher incidence of gastrointestinal and systemic complications in the TTE group (p = 0.048 and p = 0.038, respectively). CONCLUSIONS: This large-volume, multicenter study constitutes the largest cohort in the literature to compare outcomes after THE and TTE. These findings indicate the outcomes after THE and TTE for esophageal disease are equivalent, although higher-volume centers will have lower morbidity and mortality.