|Two Thousand Transhiatal Esophagectomies: Changing Trends, Lessons Learned|
|Mark B Orringer, Becky Marshall*, Andrew C. Chang*, Allan Pickens*, Christine L. Lau* |
University of Michigan Medical Center, Ann Arbor, MI
|OBJECTIVE(S): “Rediscovered” in 1976, THE has been applicable in most situations requiring esophageal resection and reconstruction . The objective of this study was to review the authors’ 30-year experience with transhiatal esophagectomy (THE) and changing trends in its use.|
METHODS: Using the authors’ prospective Esophagectomy Database, this single institution experience with THE was analyzed retrospectively.
RESULTS: 2,017 THEs were performed_1,085 (previously reported) between 1976-1998 (Group I) and 932 from 1998-2006 (Group II), 24% for benign disease, 76%, cancer. THE was possible in 98%. Stomach was the esophageal substitute in 97%. Comparing outcomes between Group I and Group II, statistically significant differences (p <0.001) were observed in hospital mortality (4% vs 1.3%); adenocarcinoma histology ( 69% vs 86%); use of neoadjuvant chemoradiation (27% vs. 51%); average blood loss (689 vs 354 cc) ; anastomotic leak (14% vs 5%); and discharge within 10 days (52% vs 76%) . Major complications remain infrequent_atelectasis/pneumonia, 2%; intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration, <1% each. Late functional results have been good or excellent in 70%. Aggressive preoperative conditioning, avoiding the ICU, improved pain management, and early ambulation reduce length of stay, 47% in Group II discharged within 1 week.
CONCLUSIONS: THE refinements have reduced the historic morbidity and mortality of esophageal resection. This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients. Avoiding and managing cervical esophagogastric anastomotic strictures are major future challenges.
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