title: Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer.
abstract: BACKGROUND
  The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO.
  
  
  METHODS
  This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion.
  
  
  RESULTS
  Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in-hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage.
  
  
  CONCLUSIONS
  There was no difference in survival or tumour recurrence for TTO and THO.
authors.affiliation: Department of Surgery, St Thomas' Hospital, King's College London, London, UK; Department of Surgery, Royal Marsden Hospital, King's College London, London, UK; Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK; Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
authors.forename: A R
authors.initials: AR
authors.lastname: Davies
authors.forename: H
authors.initials: H
authors.lastname: Sandhu
authors.forename: A
authors.initials: A
authors.lastname: Pillai
authors.forename: P
authors.initials: P
authors.lastname: Sinha
authors.forename: F
authors.initials: F
authors.lastname: Mattsson
authors.forename: M J
authors.initials: MJ
authors.lastname: Forshaw
authors.forename: J A
authors.initials: JA
authors.lastname: Gossage
authors.forename: J
authors.initials: J
authors.lastname: Lagergren
authors.forename: W H
authors.initials: WH
authors.lastname: Allum
authors.forename: R C
authors.initials: RC
authors.lastname: Mason
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods* / Q000401:mortality; D004943:Esophagogastric Junction / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008131:London / Q000453:epidemiology; D008197:Lymph Node Excision / Q000401:mortality; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome