American Surgical Association
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Vagal Sparing Esophagectomy: The Ideal Operation For High Grade Dysplasia and Early Esophageal Cancer
Christian G Peyre*, Steven R DeMeester, Christian Rizzetto*, Neeraj Bansal*, Andrew L Tang*, Shahin Ayazi*, Jessica M Leers*, John C Lipham*, Jeffrey A Hagen, Tom R DeMeester
University of Southern California, Los Angeles, CA

OBJECTIVE: Esophagectomy is curative for most patients with high grade dysplasia (HGD) or intramucosal esophageal carcinoma (IMC), but is associated with significant early and late morbidity. A vagal-sparing esophagectomy (VSE) minimizes the physiologic impact and offers the potential for reduced morbidity of esophageal resection. The aim of this study is to compare the outcome of VSE to other types of esophagectomy for patients with HGD or IMC.
METHODS: Retrospective record review of all patients who underwent a vagal-sparing, transhiatal, or en-bloc esophagectomy for HGD or IMC from 1987-2006.
RESULTS: A total of 128 patients were analyzed. Indication for operation was IMC in 43% of VS, 85.4% of TH and 100% of EB. Hospital data and outcome are listed in the table. Cancer recurrence at a median follow-up of 37, 18 and 59 months respectively, has been 1/35 patients after VS, 2/44 after TH, and 2/24 after EB.
 Vagal Sparing
(n=56)		Transhiatal
(n=48)		En Bloc
(n=24)		p value
Median Age55.567.560.00.0378
Patients with Comorbid Conditions*21.4%29.2%12.5%NS
30 Day Mortality1.8%4.2%0%NS
Median Length of Stay11.519.019.5<0.0001
Hospital Morbidity
Pneumonia
Respiratory Failure
Pleural Effusion
Abscess
Conduit Ischemia
Bacteremia/Fungemia		1.8%
0%
1.8%
0%
1.8%
3.6%		18.8%
16.7%
12.5%
6.3%
2.1%
12.5%		29.2%
16.7%
20.8%
16.7%
0%
8.3%		0.0016
0.0058
0.0178
0.0105
NS
NS
Anastomotic Complications23.2%47.9%37.5%0.0304
Symptomatic Outcome
Dumping
Diarrhea
Dysphagia
Regurgitation		7.3%
7.3%
21.8%
63.6%		15.8%
26.3%
34.2%
31.6%		36.4%
50.0%
13.6%
59.1%		0.0065
0.0002
NS
0.0075
Median Change in Weight
at 1 Year
at 2 Years		-8 lbs
-8 lbs		-21 lbs
-18 lbs		-37 lbs
-32 lbs		<0.0001
0.0494
* Major Comorbid Conditions include coronary artery disease, diabetes, arrhythmia, chronic renal failure, chronic obstructive pulmonary disease, and cirrhosis.

CONCLUSIONS: A vagal-sparing esophagectomy has significantly less early morbidity including fewer anastomotic and pulmonary complications and a shorter hospital stay than a transhiatal or en-bloc esophagectomy. Further, late morbidity including weight loss, dumping, and diarrhea are significantly reduced after a vagal-sparing approach. As cancer recurrence rates were similar for the different procedures, a vagal-sparing resection should be the esophagectomy of choice for patients with high grade dysplasia and intramucosal carcinoma.
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