Extended Transthoracic Resection Compared with Limited Transhiatal Resection for Adenocarcinoma of the Esophagus
Jan B.F. Hulscher, M.D., Johanna W. van Sandick, M.D., Angela G.E.M. de Boer, Ph.D., Bas P.L. Wijnhoven, M.D., Jan G.P. Tijssen, Ph.D., Paul Fockens, M.D., Peep F.M. Stalmeier, Ph.D., Fiebo J.W. ten Kate, M.D., Herman van Dekken, M.D., Huug Obertop, M.D., Hugo W. Tilanus, M.D., and J. Jan B. van Lanschot, M.D.
Background Controversy exists about the best surgical treatmentfor esophageal carcinoma.
Methods We randomly assigned 220 patients with adenocarcinomaof the mid-to-distal esophagus or adenocarcinoma of the gastriccardia involving the distal esophagus either to transhiatalesophagectomy or to transthoracic esophagectomy with extendeden bloc lymphadenectomy. Principal end points were overall survivaland disease-free survival. Early morbidity and mortality, thenumber of quality-adjusted life-years gained, and cost effectivenesswere also determined.
Results A total of 106 patients were assigned to undergo transhiatalesophagectomy, and 114 to undergo transthoracic esophagectomy.Demographic characteristics and characteristics of the tumorwere similar in the two groups. Perioperative morbidity washigher after transthoracic esophagectomy, but there was no significantdifference in in-hospital mortality (P=0.45). After a medianfollow-up of 4.7 years, 142 patients had died — 74 (70percent) after transhiatal resection and 68 (60 percent) aftertransthoracic resection (P=0.12). Although the difference insurvival was not statistically significant, there was a trendtoward a survival benefit with the extended approach at fiveyears: disease-free survival was 27 percent in the transhiatal-esophagectomygroup, as compared with 39 percent in the transthoracic-esophagectomygroup (95 percent confidence interval for the difference, –1to 24 percent [the negative value indicates better survivalwith transhiatal resection]), whereas overall survival was 29percent as compared with 39 percent (95 percent confidence intervalfor the difference, –3 to 23 percent).
Conclusions Transhiatal esophagectomy was associated with lowermorbidity than transthoracic esophagectomy with extended enbloc lymphadenectomy. Although median overall, disease-free,and quality-adjusted survival did not differ statistically betweenthe groups, there was a trend toward improved long-term survivalat five years with the extended transthoracic approach.
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From the Departments of Surgery (J.B.F.H., J.W.S., H.O., J.J.B.L.), Medical Psychology (A.G.E.M.B., P.F.M.S.), Cardiology (J.G.P.T.), Gastroenterology (P.F.), and Pathology (F.J.W.K.), Academic Medical Center, University of Amsterdam, Amsterdam; the Departments of Surgery (B.P.L.W., H.W.T.) and Pathology (H.D.), Erasmus University Hospital Rotterdam, Rotterdam; and RADIAN and Medical Technology Assessment (P.F.M.S.), Nijmegen — all in the Netherlands.
Address reprint requests to Dr. van Lanschot at the Academic Medical Center at the University of Amsterdam, Department of Surgery, Suite G4-112, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands, or at j.j.vanlanschot{at}amc.uva.nl.
Surgical Treatment of Esophageal Cancer
Kocher H. M., Tekkis P. P., Knisely J. P.S., Burtness B. A., Salem R. R., van Lanschot J. J. B., Tilanus H. W., Obertop H., Kitajima M., Kitagawa Y., Ozawa S.
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N Engl J Med 2003;
348:1177-1179, Mar 20, 2003.
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