Past
Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are valid surgical procedures for esophageal cancer. TTE allows for more extensive lymphadenectomy via thoracic dissection, while THE has been preferred in frail patients, as some studies have shown higher morbidity and short-term mortality after TTE. Both of these procedures can also be performed with minimally invasive techniques. However, available evidence of long-term oncological outcomes after THE compared with TTE1,2 is contradictory, and there is also a lack of population-based studies. So far, existing studies do not show superiority of either approach in treatment of esophageal cancer, and the largest published meta-analysis of 52 studies found no difference in 5-year overall survival.3
Present
We conducted a population-based, nationwide cohort study including all 1338 patients with esophageal cancer undergoing curatively intended THE and TTE in Finland from 1987 to 2016.4 We used Cox regression adjusted for confounders to investigate 5-year and 90-day survival, as well as explanatory subgroup analyses. The observed 5-year survival was 39.3% after THE and 45.0% after TTE, and 90-day observed survival was 89.5% versus 92.3%, respectively. However, no statistically significant differences were present in 5-year or 90-day observed survival comparing THE with TTE in any of the adjusted models, nor in the five subgroups examined.
Future
The present study suggests similar 5-year survival after THE and TTE. Despite higher counts of examined lymph nodes in the transthoracic approach, no difference in long-term survival was present. The cervical anastomosis inherent to the THE technique has been associated with higher leak rates; however, leaks after TTE can be more severe due to mediastinal manifestations. In the current study, complication rates were not studied; however, 90-day mortality rates were similar after THE and TTE. Although it seems from this evidence that the surgical approach can be chosen on the basis of surgeon preference, further studies are needed, especially on certain subgroups such as tumors with high T-stage, tumors located in the middle third of the esophagus, those with lymph node metastases in thoracic nodes, and operations performed with minimally invasive techniques.
Acknowledgements
FINEGO (The Finnish National Esophago-Gastric Cancer Cohort) collaborative group: Olli Helminen: Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. Mika Helmiö: Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland. Heikki Huhta: Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. Raija Kallio: Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland. Vesa Koivukangas: Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. Arto Kokkola: Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. Simo Laine: Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland. Elina Lietzen: Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland. Sanna Meriläinen: Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. Vesa-Matti Pohjanen: Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland. Tuomo Rantanen: Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland. Ari Ristimäki: Department of Pathology, HUSLAB, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland and Applied Tumor Genomics Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland. Jari V. Räsänen: Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. Juha Saarnio: Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. Eero Sihvo: Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland. Vesa Toikkanen: Department of Cardiothoracic Surgery, Heart Center, Tampere University Hospital and University of Tampere, Tampere, Tampere, Finland. Tuula Tyrväinen: Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. Antti Valtola: Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
Funding
Open Access funding provided by University of Turku (UTU) including Turku University Central Hospital.
Disclosure
The authors report no conflict of interest.
Footnotes
Publisher's Note
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Contributor Information
Anna Junttila, Email: anna.junttila@fimnet.fi.
the FINEGO Group:
Olli Helminen, Mika Helmiö, Heikki Huhta, Raija Kallio, Vesa Koivukangas, Arto Kokkola, Simo Laine, Elina Lietzen, Sanna Meriläinen, Vesa-Matti Pohjanen, Tuomo Rantanen, Ari Ristimäki, Jari V. Räsänen, Juha Saarnio, Eero Sihvo, Vesa Toikkanen, Tuula Tyrväinen, and Antti Valtola
References
- 1.Omloo JMT, Lagarde SM, Hulscher JBF, Reitsma JB, Fockens P, van Dekken H, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg. 2007;246(6):991–992. doi: 10.1097/SLA.0b013e31815c4037. [DOI] [PubMed] [Google Scholar]
- 2.Kalff MC, Fransen LFC, de Groot EM, Gisbertz SS, Nieuwenhuijzen GAP, Ruurda JP, et al. Long-term survival after minimally invasive versus open esophagectomy for esophageal cancer: a nationwide propensity-score matched analysis. Ann Surg. 2020 doi: 10.1097/SLA.0000000000004708. [DOI] [PubMed] [Google Scholar]
- 3.Boshier PR, Anderson O, Hanna GB. Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis. Ann Surg. 2011;254(6):894–906. doi: 10.1097/SLA.0b013e3182263781. [DOI] [PubMed] [Google Scholar]
- 4.Junttila A, Helminen O, Helmiö M, Huhta H, Kallio R, Koivukangas V, et al. Long-term survival after transhiatal versus transthoracic esophagectomy: a population-based nationwide study in Finland. Ann Surg Oncol. 2022 doi: 10.1245/s10434-022-12349-8. [DOI] [PMC free article] [PubMed] [Google Scholar]