Transhiatal esophagectomy for treatment of benign and malignant esophageal disease.
Since our initial 1978 report, we have performed transhiatal esophagectomy (THE) in 1085 patients with intrathoracic esophageal disease: 285 (26%) benign lesions and 800 (74%) malignant lesions (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was possible in 97% of patients in whom it was attempted; reconstruction was performed at the same operation in all but six patients. The esophageal substitute was positioned in the original esophageal bed in 98%, stomach being used in 782 patients (96%) and colon in those with a prior gastric resection. Hospital mortality was 4%, with three deaths due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak (13%), atelectasis/pneumonia prolonging hospitalization (2%), recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (< 1% each). There were five reoperations for mediastinal bleeding within 24 hours of THE. Intraoperative blood loss averaged 689 ml. Altogether, 78% of the patients had no postoperative complications. Actuarial survival of the cancer patients mirrors that reported after transthoracic esophagectomy. Late functional results are good or excellent in 80%. Approximately 50% have required one or more anastomotic dilatations. With intensive preadmission pulmonary and physical conditioning, use of a side-to-side staple technique (which has reduced the cervical esophagogastric anastomotic leak rate to less than 3%), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of hospital stay was reduced to 7 days. We concluded that THE can be achieved in most patients requiring esophageal resection for benign and malignant disease and with greater safety and less morbidity than the traditional transthoracic approaches.
Orringer
M B
MB
Section of General Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, 2120 Taubman Health Care Center, 1500 E. Medical Center Drive, Box 0344, Ann Arbor, Michigan 48109, USA. morrin@umich.edu
Marshall
B
B
Iannettoni
M D
MD
D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery; D004935:Esophageal Diseases / Q000401:mortality / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D009367:Neoplasm Staging; D019651:Plastic Surgery Procedures; D013270:Stomach / Q000601:surgery; D017792:Surgical Stapling