Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures

BACKGROUND: Transhiatal and transthoracic esophagectomy are common approaches for esophageal resection. The literature is limited regarding the combined thoracoscopic and laparoscopic approach to esophagectomy. The aim of this study was to evaluate the outcomes of combined thoracoscopic and laparoscopic esophagectomy for the treatment of benign and malignant esophageal disease. STUDY DESIGN: We performed a retrospective chart review of 46 consecutive minimally invasive esophagectomies performed between August 1998 and September 2002. Indications for esophagectomy were carcinoma (n = 38), Barrett's esophagus with high-grade dysplasia (n = 3), and recalcitrant stricture (n = 5). Of 38 patients with carcinoma 23 (61%) had neoadjuvant therapy. The main outcome measures were operative time, blood loss, length of intensive care unit and hospital stay, conversion rate, morbidity, mortality, pathology, disease recurrence, and survival. RESULTS: Approaches to esophagectomy were thoracoscopic and laparoscopic esophagectomy (n = 41), thoracoscopic and laparoscopic Ivor Lewis resection (n = 3), abdominal only laparoscopic esophagogastrectomy (n = 1), and hand-assisted laparoscopic transhiatal esophagectomy (n = 1). Minimally invasive esophagectomy was successfully completed in 45 (97.8%) of 46 patients. The mean operative time was 350 +/- 75 minutes and the mean blood loss was 279 +/- 184 mL. The median length of intensive care unit stay was 2 days and median length of stay was 8 days. Major complications occurred in 17.4% of patients and minor complications occurred in 10.8%. Late complications were seen in 26.1% of patients. The overall mortality was 4.3%. Among the 38 patients who underwent esophagectomy for cancer the 3-year survival was 57%. In a mean followup of 26 months there was no trocar site or neck wound recurrences. CONCLUSIONS: A thoracoscopic and laparoscopic approach to esophagectomy is technically feasible and safe for the treatment of benign and malignant esophageal disease. With a mean followup of 26 months thoracoscopic and laparoscopic esophagectomy appears to be an oncologically acceptable surgical approach for the treatment of esophageal cancer.     

Minimally invasive esophagectomy

BACKGROUND: Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS: From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS: Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS: Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.     

Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival

Background Surgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications. Methods The authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere. Results The study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better. Conclusions The transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease. Presented as a “free paper” during the 9th World Congress of Endoscopic Surgery, Cancun, Mexico, 4-7 February, 2004     

Laparoscopic transhiatal esophagectomy for esophageal cancer

BACKGROUND: Traditional esophagectomy may be associated with mortality, considerable morbidity, and lengthy recovery. It is often performed in cancer patients who are typically older, have associated comorbidities, and are often malnourished, all factors that increase surgical risk. Minimally invasive esophagectomy has the potential advantages of being a less traumatic procedure with an easier postoperative recovery and fewer wound and pulmonary complications. METHODS: A retrospective analysis of patients who underwent laparoscopic transhiatal esophagectomy was performed. Assessed parameters included patient demographics and operative data, pathology results, and long-term follow-up of at least 12 months. RESULTS: Twenty-two patients underwent laparoscopic transhiatal esophagectomy; 19 had esophageal cancer. Two patients were operated on for Barrett esophagus, and 1 patient had achalasia. The majority of patients were men (82%), and the mean age was 59 years (range 15 to 74 years); 1 patient (4.5%) was converted to open surgery. The average operative time was 380 minutes (range 285 to 525 minutes), and the average blood loss was 220 mL; only 3 patients required transfusion. The median hospital stay was 8 days (range 5 to 46 days). Postoperative mortality occurred in 1 patient (4.5%), and postoperative complications developed in 6 patients (27.2%). In the 19 cancer patients, the average number of harvested nodes was 14.3 (range 10 to 19). The average follow-up was 30 months (range 12 to 48 months). The overall survival for cancer patients was 61% (11 of 19), and disease-free survival was 39% (7/19). CONCLUSIONS: Esophagectomy is a major surgery with considerable morbidity and potential mortality. Minimally invasive esophagectomy is a feasible approach that can be safely performed by surgeons with extensive experience in that field. Advantages include less intraoperative blood loss, a smaller incision, and a potentially faster postoperative recovery. In cancer patients, immediate oncologic goals of adequate margins and lymph node dissection can be achieved, and long-term outcome appears to be similar to that found with open approaches.     

Limited operation for patients with T1 esophageal cancer

BACKGROUND/AIMS: Transhiatal esophagectomy without thoracotomy has been introduced as a minimally invasive operation to prevent postoperative complications in patients with relatively early-stage esophageal cancer who have preoperative pulmonary or cardiovascular complications or who are in a high age bracket. However, this procedure for patients with esophageal cancer remains controversial, especially as regards curative surgery because complete intrathoracic lymphadenectomy cannot be performed in this operation. Thus, cancer recurrence after this operation has been considered to be high. To evaluate the benefits of this less invasive surgery for patients with T1 esophageal cancer, the prognoses of patients who underwent transhiatal esophagectomy without thoracotomy were compared with those of patients who underwent traditional esophagectomy with thoracotomy. METHODS: Between 1989 and 1998, 33 patients with T1 esophageal cancer were operated on in our hospital. We introduced transhiatal esophagectomy without thoracotomy in 19 patients who were over 70 years old or who had preoperative complications (transhiatal group). The remaining 14 patients were treated with the transthoracic procedure (transthoracic group). These 33 patients were followed up at our hospital until the end of 1999. The postoperative complications and prognoses in the two groups were compared. RESULTS: We were able to reduce the operation time using the transhiatal procedure. Even though no significant difference was detected, there were fewer postoperative pulmonary complications with this procedure (11%) than with the transthoracic procedure (21%). The incidences of in-hospital mortality did not differ between the two groups. Cancer recurrence was detected in 5 of 19 patients (26%) in the transhiatal group and in 5 of 14 patients (36%) in the transthoracic group; no difference was observed (P=0.562). The 5-year survival rate (58%) of the transhiatal group was no different from that of the transthoracic group (62%, P=0.69). CONCLUSIONS: Complete intrathoracic lymphadenectomy cannot be performed along with transhiatal esophagectomy; however, the prognoses of patients who were treated with this procedure were no different from those of patients who were treated with transthoracic esophagectomy. Thus, transhiatal esophagectomy without thoracotomy might be a justifiable operation for compromised patients with T1 esophageal cancer.     

Minimally invasive esophagectomy: early experience and outcomes

Minimally invasive esophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. A case series of 20 patients who underwent minimally invasive total esophagectomy is presented. This study was a review of a prospective database. The purpose was to evaluate early results with laparoscopic total esophagectomy for benign and malignant disease. Between January 2003 and November 2005, 20 patients underwent minimally invasive esophageal surgery. All operations were performed by the same two surgeons. Age, gender, indications for surgery, pathologic stage, operative time, blood loss, transfusion requirements, intensive care unit length of stay, hospital length of stay, postoperative complications, and mortality were recorded. Diet progression, dysphagia, and need for stricture management were also recorded. Of the 20 minimally invasive total esophagectomies performed, 18 (90%) were completed successfully. The average age of the patients was 53 years. Indications for surgery were malignancy (n = 13), carcinoma in situ in the setting of Barrett's esophagus (n = 2), and benign stricture (n = 3). The average operating time was 467 minutes (range 346-580 min). Median blood loss was 350 mL (range 150-500 mL). The median intensive care unit stay was 2 days, and the median hospital length of stay was 12 days. Pathology revealed that 7 per cent of patients had stage I disease, 27 per cent of patients had stage II disease, and 53 per cent of patients had stage III disease. There was a single mortality (5%), a cervical leak in two patients (10%), a gastric tip necrosis in one patient (5%), and tracheoesophageal fistula in one patient (5%). Major complications occurred in eight patients (40%) and minor complications in nine (50%). Thirteen (72%) patients were discharged on enteral tube feeds to supplement caloric intake. The application of minimally invasive techniques in the arena of esophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total esophagectomy is feasible.     

Laparoscopic versus open gastroplasty in esophagectomy for esophageal cancer: a comparative study

How best to approach esophagectomy is a controversial issue. In the last decade, the opportunity to use minimally invasive surgical methods for esophagectomy has been documented, but their real advantages over conventional surgery have yet to be clearly established. The aim of this study was to compare a series of patients who underwent laparoscopic esophagectomy with those who underwent open surgery to ascertain the feasibility, safety, and clinical advantages of the former surgical techniques. Between January 2002 and May 2004, 14 patients with cancer of the esophagus underwent laparoscopic esophagectomy and another 14 had conventional open esophagectomy. Their demographic features, and intraoperative and postoperative data were compared. The 2 groups were comparable in terms of age, American Society of Anesthesiologists score, and site of the neoplasm. The operating times were the same for transhiatal laparoscopic esophagectomy and conventional surgery, although using the thoraco-laparoscopic access took longer than the thoraco-laparotomic procedure (P<0.05). The hospital stay was shorter after laparoscopy (P<0.05). No differences emerged in terms of morbidity, mortality, number of transfusions, and time in the intensive care. The numbers of lymph nodes removed were comparable. In conclusion, it is feasible and safe to use a laparoscopic approach instead of open surgery for esophagectomy, but the former does not offer very significant clinical advantages in the postoperative stage. A shorter hospital stay seems to be the most significant finding. The minimally invasive procedure would seem to assure oncological radicality because it enables lymphadenectomy to be as thorough as in the conventional surgical approach.     

Transhiatal esophagectomy: a safe alternative for selected patients.

One hundred one consecutive patients underwent an esophagectomy with gastric interposition for benign and malignant processes from January 1982 through July 1990. Seventy-seven underwent transhiatal esophagectomy and 24, transthoracic esophagectomy. Multivariate analysis was performed comparing the hospitalization experience of the two groups. There was no significant difference found between the mean intraoperative blood loss for transhiatal esophagectomy (770 +/- 105 mL) and that of transthoracic esophagectomy (700 +/- 175 mL). There was a significant difference between operative time, with transhiatal esophagectomy averaging 5.4 hours and transthoracic esophagectomy averaging 7.3 hours. Postoperative stay was not significantly different although there was a wide range of values for the transthoracic esophagectomy group. An 8% operative mortality was experienced by both groups. There were a significant number of minor anastomotic leaks at the cervical anastomotic level for the transhiatal esophagectomy group, but all responded to nonoperative management. The highest morbidity and mortality were seen in the subgroup of transhiatal esophagectomies done for laryngocervical malignancies. The lowest morbidity and mortality were seen in the subgroup of 12 patients who underwent transhiatal esophagectomy for nonmalignant esophageal conditions. Transhiatal esophagectomy appears to be a safe alternative for early intrathoracic esophageal malignancies at any level, for bulky distal esophageal lesions, and for benign conditions requiring total esophagectomy.     

An audit of surgical outcomes of esophageal squamous cell carcinoma.

OBJECTIVE: Esophageal squamous cell carcinoma and adenocarcinoma were increasingly recognized as two entities with different biologic behaviors and prognosis. Surgical risks and oncologic benefits of transthoracic and transhiatal esophagectomy for esophageal squamous cell carcinoma patients are not confessed. METHODS: Between 1994 and 2005, 216 esophageal squamous cell carcinoma patients underwent esophagectomy were enrolled and analyzed retrospectively. RESULTS: One hundred sixty-six patients underwent transthoracic esophagectomy and 50 patients underwent transhiatal esophagectomy. The overall hospital mortality and postoperative complication rates were 9.7 and 49%, respectively. The amount of intra-operative blood loss or transfusion, postoperative complication rate, lengths of hospital stay and hospital mortality rate were not significantly different between both groups. However, shorter operative time was noticed in transhiatal group (p<0.001). The overall 5-year survival rate was 16.8%. ESCC patients underwent either transthoracic or transhiatal esophagectomy had comparable long-term survival. The pTNM stage was independent prognostic factor for patients underwent transthoracic esophagectomy. However, location of tumor (p=0.009) and pathologic tumor length (p=0.012) were predictors of prognosis for patients underwent transhiatal esophagectomy. CONCLUSIONS: For esophageal squamous cell carcinoma patients, no significant differences in postoperative mortality or morbidity rates were observed between transthoracic and transhiatal esophagectomy. However, traditional pTNM staging system might underestimate the severity of esophageal squamous cell carcinoma patients who underwent transhiatal esophagectomy. The information of dissimilar prognostic factors for transhiatal or transthoracic esophagectomies will be helpful in tailoring more individualized adjuvant therapy to optimize esophageal squamous cell carcinoma patient's outcome.     

Minimally invasive transhiatal esophagectomy: lessons learned

Background Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned. Methods A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival. Results Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36–79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1–3), and 1 for high-grade dysplasia in Barrett’s. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180–450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). At a median follow-up of 13 months (range = 4–42), 13 patients were alive. Conclusions Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.     

Experience with minimally invasive esophagectomy

Background Minimally invasive esophagectomy (MIE) is an evolving surgical alternative to traditional open esophagectomy. Despite considerable technical challenges, it was hypothesized that MIE could be performed effectively by surgeons experienced in open esophageal resection and advanced laparoscopic surgery. The authors report their experience with 25 patients who underwent MIE for esophageal disease. Methods A multidisciplinary esophageal cancer team evaluated all the patients enrolled in this institutional review board–approved retrospective review study. Over an 18-month period, 25 consecutive patients (22 men and 3 women; mean age, 62 years; range, 48–77 years) with resectable esophageal cancer underwent MIE. Six patients were treated with neoadjuvant chemoradiotherapy. The preoperative diagnoses were adenocarcinoma (64%, n = 16), high-grade dysplasia (20%, n = 5), and squamous cell cancer (16%, n = 4). The outcomes evaluated included operative course, hospital and intensive care unit lengths of stay, pathologic stage, morbidity, and mortality. Results Two patients required conversion to open esophagectomy. Operative mortality was 4% (n = 1). The mean operative time was 350 min (range, 300–480), and the average blood loss was 200 ml. The patients remained ventilated for a median of 12 h, and the median intensive care unit utilization was 1 day. The median hospital length of stay was 9 days (range, 6–33 days). Major complications occurred in 32% of the patients. The anastomotic leak rate was 12%. Minor pulmonary complications occurred in 32% and atrial fibrillation in 16% of the patients. An anastomotic stricture developed in 24% of all the patients. One patient showed a positive proximal margin in the final pathology results. Conclusions Minimally invasive esophagectomy is a technically challenging procedure that can be performed safely at the Virginia Piper Cancer Institute. Optimal results require appropriate patient selection and a multidisciplinary team experienced in the management of esophageal cancer.     

Minimally invasive esophagectomy in a previously pneumonectomized patient

Abstract Introduction: Surgical resection represents the only therapeutic action having a radical intent for the treatment of resectable esophageal neoplasms. Minimally invasive esophagectomy for esophageal cancer is being more and more frequently performed. Few cases of esophagectomy after pneumonectomy have been described in the literature, and, to our knowledge, none of them was performed by the minimally invasive technique. Subject and Methods: A 77-year-old woman, who had undergone left thoracotomic pneumonectomy due to squamous cell lung cancer 2 years before, underwent minimally invasive esophagectomy because of esophageal cancer at the authors' institution. The intervention was performed by right thoracoscopic esophageal mobilization with the patient in the prone position, followed by the laparoscopic and cervicotomic stages, with cervical anastomosis. Results: Total operative time was 230 minutes. Intensive care unit stay was 1 day, followed by a hospital stay of 13 days. We did not observe any major postoperative complication. Conclusions: Minimally invasive esophagectomy with thoracoscopic esophageal mobilization in the prone position is a valid option in the treatment of esophageal cancer and may be feasible in previously left pneumonectomized patients.     

Transhiatal blunt esophagectomy for carcinoma of the esophagus.

Transhiatal blunt esophagectomy has been reported as a safe and effective procedure for the palliation of carcinoma of the esophagus. Avoidance of a thoracotomy eliminates the morbidity associated with this procedure, and creation of a cervical esophagogastric anastomosis avoids the catastrophic sequelae of an intrathoracic anastomotic leak. Moreover, use of the procedure for palliation does not preclude excellent 1-year survival rates. We report early results in five consecutive patients with esophageal carcinoma who underwent transhiatal blunt esophagectomy. Five patients had 22 complications, including one with a fascial dehiscence, pyloroplasty leak, and localized mediastinal abscess requiring a second laparotomy. One patient died in the hospital postoperatively of massive aspiration pneumonitis. Our results compare favorably with those reported in the literature. We believe that transhiatal blunt esophagectomy avoids the morbidity and mortality of a thoracotomy and an intrathoracic anastomosis, yet remains a major gastrointestinal operative procedure with all of its attendant risks.     

Minimally invasive esophagectomy for Barrett's esophagus with high-grade dysplasia

BACKGROUND: Barrett's esophagus with high-grade dysplasia (BE/HGD) is associated with invasive carcinoma in 30% to 70% of cases. Esophagectomy is the treatment of choice for patients with BE/HGD but esophagectomy can be associated with high morbidity and mortality. The aim of our study was to report our preliminary experience in applying minimally invasive surgical techniques to esophagectomy for BE/HGD. METHODS: From August 1996 to February 1999, 12 consecutive patients underwent minimally invasive esophagectomy for biopsy-proven BE/HGD. Our consort consisted of 7 men and 5 women; average age was 64 years (range, 40-78 years). All patients underwent a complete laparoscopic or combined laparoscopic and thoracoscopic resection of the esophagus with cervical anastomosis. RESULTS: Mean operative time was 7.8 +/- 2.1 hours, mean intensive care unit stay was 2.6 +/- 2.2 days, and mean length of hospital stay was 8.3 +/- 4.7 days. Five patients (42%) had carcinoma in situ or carcinoma identified on pathologic specimen. Analyses of all resected lymph nodes in the 12 patients were negative for metastatic disease. There were 6 major complications in 5 patients: 1 patient had a small bowel perforation requiring operative repair, 2 patients needed prolonged ventilatory support for respiratory insufficiency, and 3 patients had delayed gastric emptying requiring revision of the pyloromyotomy. The single minor complication in this series was a jejunostomy tube-site infection. There were no conversions to laparotomy or thoracotomy. All patients were alive and free of metastatic disease at a mean follow-up of 12.6 months. CONCLUSIONS: Minimally invasive esophagectomy is a feasible and safe alternative to conventional open esophagectomy for patients with BE/HGD.     

Robotic-assisted transhiatal esophagectomy

Background Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis.Materials and methods The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy.Results Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome.Conclusion The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.     

Thoracoscopic and laparoscopic esophagectomy

Esophagectomy is both complex and challenging, and it may be associated with significant morbidity and mortality. With improvements in instrumentation and increasing experience with laparoscopic and thoracoscopic techniques, minimally invasive approaches to esophagectomy are being explored to determine feasibility, results, and potential advantages. Most of this experience has been with case studies or small series, with many surgeons using thoracoscopy in combination with standard laparotomy. Many of the patients have been carefully selected for these procedures because they have small tumors or high-grade dysplasia. Our technique for esophagectomy has evolved from a laparoscopic transhiatal approach to a combined laparoscopic and thoracoscopic approach. Our experience with this procedure has increased, and now we offer this approach to the majority of patients with resectable cancers. We review our operative technique and the results of surgery in our first 50 patients who underwent minimally invasive esophagectomy for cancer or high-grade dysplasia.     

Transhiatal esophagectomy

Controversy still remains regarding the appropriateness of THE asa cancer operation. Critics argue that without an en bloc mediastinal lymphadenectomy, THE does not provide accurate staging or the potential for a curative procedure; however, operative margins are similar after transthoracic and transhiatal esophagectomy, and van Sandick and co-workers reported that 73% of margins were microscopically negative. In many cases, esophageal carcinoma appears to be a systemic disease at the time of diagnosis. According to Orringer and colleagues, 46% of patients have Stage III or IV disease at the time of operation, and Altorki and co-authors found that 35% of patients thought to be potentially curable were found to have occult cervical lymph node disease after three-field lymph node dissection. In addition, survival after THE is similar to that reported after transthoracic esophagectomy as well as radical esophagectomy with mediastinal lymphadenectomy. The most important determinants of survival appear to be the biologic behavior of the tumor and the stage at the time of resection rather than the operative approach, and esophageal carcinoma will likely require systemic therapy for a cure.Transhiatal esophagectomy has been used increasingly in the resection of benign and malignant disease, and has several potential advantages over transthoracic esophagectomy, including significantly decreased respiratory complications and mediastinitis due to the avoidance of thoracotomy and intrathoracic anastomosis. In a meta-analysis of fifty studies comparing transthoracic and transhiatal resection, Hulscher et al found significantly higher early morbidity and mortality rates after transthoracic resections, which was confirmed in a later randomized study of 220 patients(Table 2). Survival after THE is also equivalent to or better than that seen after transthoracic esophagectomy, and transhiatal esophagectomy should be considered in all patients requiring esophagectomy for benign or malignant disease.     

Transhiatal esophagectomy

Between 1991-2001, 40 patients underwent esophagectomy without thoracotomy for: caustic esophageal stenosis (26 cases), cervical esophageal cancer (1), lower esophageal cancer (7), and acute post-caustic oesophagitis (2). Thirty-four patients underwent transhiatal esophagectomy, 3 patients had an esophagectomy by "stripping" and in 3 other patients a combination of stripping and transhiatal esophagectomy. Postoperative complications included: injuries of the laryngeal recurrent nerve (2), pulmonary complications (13), anastomotic leakage (5). Two patients died in the postoperative period one from a myocardial infarction and the other from an acute myocardial dilatation. Trans-hiatal esophagectomy can be considered as a viable alternative to transthoracic esophagectomy in the management of the benign and malignant diseases of the esophagus. Transhiatal esophagectomy is a safe method of resection because of its reported lower morbidity and mortality and similar survival rates compared to transthoracic esophagectomy.     

A decade of experience with transthoracic and transhiatal esophagectomy

BACKGROUND: Morbidity and mortality remain significant for transthoracic (TT) and transhiatal (TH) esophagectomy. We report a case-specific approach employing either resection to minimize perioperative morbidity and mortality. METHODS: All primary esophageal resections performed for benign and malignant esophageal disease were reviewed over a 10-year period. The operative approach was tailored to the location and extent of disease and the physiologic reserve of the patient. RESULTS: In all, 115 patients underwent esophagectomy for benign (25) and malignant (90) disease. Fifty-six TT and 59 TH resections were performed. Four emergent TT cases did not have reconstruction. There was 1 hospital mortality. Perioperative transfusion was avoided in 65 patients. Respiratory complications occurred in 15. Three patients had a cervical anastomotic leak requiring open wound drainage. No association between resection type and complication was evident. CONCLUSIONS: The judicious use of both TT and TH esophagectomy resulted in an operative mortality of less than 1%, reduced operative blood loss, and a relatively low rate of perioperative complications.     

Robotically assisted laparoscopic transhiatal esophagectomy

Background Esophagectomy is a technically demanding operation with high procedure-related morbidity and mortality rates. Minimally invasive techniques were introduced in the late 1980s in an effort to decrease the invasiveness of the procedure. Data concerning the use of robotic systems for esophageal cancer are scarce in the literature. The goal of this report is to describe the authors’ early experience using robotically assisted technology to perform transhiatal esophagectomy (RATE). Methods Between September 2001 and May 2004, 18 patients underwent RATE at the authors’ institution. A retrospective review of prospectively collected data was performed. Gender, age, postoperative diagnosis, operative time, conversion rate, blood loss, hospital stay, length of the follow-up period, and complications were assessed. Results At the authors’ institution, 18 patients underwent RATE, including 16 men (89%), with a mean age of 54 years (range, 41–73 years). The RATE procedure was completed for all 18 patients (100%). The mean operative time was 267 ± 71 min, and estimated blood loss was 54 ml (range, 10–150 ml). The mean intensive care unit stay was 1.8 days (range, 1–5 days), and the mean hospital stay was 10 days (range, 4–38 days). A total of 12 perioperative complications occurred for 9 patients, including 6 anastomotic leaks, 1 thoracic duct injury, 1 vocal cord paralysis, 1 pleural effusion, and 2 atrial fibrillations. Anastomotic stricture was observed in six patients. There were no perioperative deaths. Pathologic examination of the surgical specimen yielded an average of 14 lymph nodes per patient (range, 7–27). During the mean follow-up period of 22 ± 8 months, 2 patients died, 2 were lost to follow-up evaluation, 3 had recurrence, and 11 were disease free. Conclusion The current study shows that RATE, with its decreased blood loss, minimal cardiopulmonary complications, and no hospital mortality, represents a safe and effective alternative for the treatment of esophageal adenocarcinoma.