title: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.
abstract: BACKGROUND
  Controversy exists about the best surgical treatment for esophageal carcinoma.
  
  
  METHODS
  We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined.
  
  
  RESULTS
  A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died--74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent).
  
  
  CONCLUSIONS
  Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.
authors.affiliation: Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Jan B F
authors.initials: JB
authors.lastname: Hulscher
authors.forename: Johanna W
authors.initials: JW
authors.lastname: van Sandick
authors.forename: Angela G E M
authors.initials: AG
authors.lastname: de Boer
authors.forename: Bas P L
authors.initials: BP
authors.lastname: Wijnhoven
authors.forename: Jan G P
authors.initials: JG
authors.lastname: Tijssen
authors.forename: Paul
authors.initials: P
authors.lastname: Fockens
authors.forename: Peep F M
authors.initials: PF
authors.lastname: Stalmeier
authors.forename: Fiebo J W
authors.initials: FJ
authors.lastname: ten Kate
authors.forename: Herman
authors.initials: H
authors.lastname: van Dekken
authors.forename: Huug
authors.initials: H
authors.lastname: Obertop
authors.forename: Hugo W
authors.initials: HW
authors.lastname: Tilanus
authors.forename: J Jan B
authors.initials: JJ
authors.lastname: van Lanschot
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D018572:Disease-Free Survival; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000191:economics / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D019057:Quality-Adjusted Life Years; D016019:Survival Analysis