title: Two thousand transhiatal esophagectomies: changing trends, lessons learned.
abstract: OBJECTIVE
  "Rediscovered" in 1976, transhiatal esophagectomy (THE) has been applicable in most situations requiring esophageal resection and reconstruction. The objective of this study was to review the authors' 30-year experience with THE and changing trends in its use.
  
  
  METHODS
  Using the authors' prospective Esophagectomy Database, this single institution experience with THE was analyzed retrospectively.
  
  
  RESULTS
  Two thousand and seven THEs were performed-1063 (previously reported) between 1976 and 1998 (group I) and 944 from 1998 to 2006 (group II), 24% for benign disease, 76%, cancer. THE was possible in 98%. Stomach was the esophageal substitute in 97%. Comparing outcomes between group I and group II, statistically significant differences (P < 0.001) were observed in hospital mortality (4% vs. 1%); adenocarcinoma histology (69% vs. 86%); use of neoadjuvant chemoradiation (28% vs. 52%); mean blood loss (677 vs. 368 mL); anastomotic leak (14% vs. 9%); and discharge within 10 days (52% vs. 78%). Major complications remain infrequent: wound infection/dehiscence, 3%, atelectasis/pneumonia, 2%, intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration, <1% each. Late functional results have been good or excellent in 73%. Aggressive preoperative conditioning, avoiding the ICU, improved pain management, and early ambulation reduce length of stay, with 50% in group II discharged within 1 week.
  
  
  CONCLUSIONS
  THE refinements have reduced the historic morbidity and mortality of esophageal resection. This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients.
authors: Section of General Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA. morrin@umich.edu
authors: Mark B
authors: MB
authors: Orringer
authors: Becky
authors: B
authors: Marshall
authors: Andrew C
authors: AC
authors: Chang
authors: Julia
authors: J
authors: Lee
authors: Allan
authors: A
authors: Pickens
authors: Christine L
authors: CL
authors: Lau
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D004434:Early Ambulation; D004935:Esophageal Diseases / Q000401:mortality / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D013270:Stomach / Q000637:transplantation; D015996:Survival Rate; D016896:Treatment Outcome
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