Esophagectomy without thoracotomy: 25 years of experience over 750 patients.

OBJECTIVE: This study aimed to review and evaluate our experience in 750 patients, who underwent transhiatal esophagectomy (THE) and analyze our data. Special attention was paid to some strategies, which we developed in the course of time, regarding the postoperative management of these patients and formulation of improved guidelines.

PATIENTS AND METHODS: This is a retrospective analysis of all THE operations performed between January 1981 until May 2007 in 750 patients: 60 patients (8%) had benign lesions, while 690 (92%) had malignant ones (5.2% of malignancies were located in the upper esophagus, 7.4% in the middle esophagus, 19% in the lower esophagus, and 68.4% at the cardioesophageal junction). THE and esophageal reconstruction were performed at the same operation in all patients. The stomach was our esophageal substitute of first choice with the colon and jejunum being acceptable alternatives in patients with prior gastric surgery and those necessitating synchronous gastrectomy for cancer invasion. A gastric tube was used as an esophageal substitute in 624 patients (83.2%), the whole stomach in 70 (9.4%), the colon in 43 (5.73%), and a jejunal loop in 13 (1.73%).

RESULTS: The overall in-hospital mortality rate was 2.93% (22 patients). There was no intraoperative death. Major complications included atelectasis or pneumonia (4.8%), pleural effusion (22.7%), myocardial infarction (0.5%), recurrent laryngeal nerve paralysis (1.33%), and three tracheal lacerations (0.4%). The anastomotic leak rate decreased gradually over time from 29.4% to 11.1% in the last 6 years. The average intraoperative blood loss was 315 ml and 82% of the patients did not receive any blood transfusion. Late functional results were good or excellent in 93%. The average length of hospital stay was 11 days and intensive care unit stay was 2.3 days. The actuarial 5-year survival rate after THE for carcinoma was 21%.

CONCLUSION: THE is a safe and effective method of esophageal resection with low morbidity and mortality rates and good functional results when performed by experienced surgeons. We believe that our strategies concerning the way of dissecting the cervical esophagus, avoidance of performing pyloromyotomy, the delayed removal of the cervical drain and the delayed advance to oral feeding have reduced, noticeably, morbidity and mortality in our series.