title: What should be the gold standard for the surgical component in the treatment of locally advanced esophageal cancer: transthoracic versus transhiatal esophagectomy.
abstract: OBJECTIVE
  To analyze survival differences between transthoracic esophagectomy (TTE) and limited transhiatal esophagectomy (THE) in clinically (cT3) and pathologically (pT3) staged advanced tumors without neoadjuvant treatment.
  
  
  BACKGROUND
  Debate exists whether in the type of resection in locally advanced cancer plays a role in prognosis and whether THE is a valuable alternative to TTE regarding oncological doctrine and overall survival.
  
  
  METHODS
  In a retrospective study of 2 high-volume centers, 468 patients with cT3NXM0 esophageal cancer, including 242 (51.7%) squamous cell carcinomas (SCCs) and 226 (48.3%) adenocarcinomas (ACs), were analyzed. A total of 341 (72.9%) TTE and 127 (27.1%) THE were performed. We used the propensity score matching to build comparable groups. Primary endpoint was the overall survival; secondary endpoints included resection status and lymph node yield.
  
  
  RESULTS
  TTE achieved a higher rate of R0 resections (86.2% vs 73.2%; P = 0.001) and a higher median lymph node yield (27.0 ± 12.4 vs 17.0 ± 6.4; P < 0.001) than THE. Thirty-day mortality rate was 6.6% (8/121) for TTE and 7.4% (9/121) for THE (P = 0.600). In the matched groups, TTE was beneficial for pT3 SCC (P = 0.004), pT3 AC (P = 0.029), cT3 SCC (P = 0.018), and cT3 AC (P = 0.028) patients. TTE was either beneficial in pN2 disease for cT3 AC + SCC or pT3 SCC but not for pT3 AC patients, without nodal stratification in pT3 and cT3 SCC node-positive patients. On multivariable analysis, TTE remained an independent factor for survival.
  
  
  CONCLUSIONS
  Extended TTE achieved a higher rate of R0 resections, a higher lymph node yield, and resulted in a prolonged survival than THE in pT3, cT3, and node-positive patients.
authors.affiliation: *Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Germany, and †Department of General, Visceral and Cancer Surgery, University of Cologne, Germany.
authors.forename: Asad
authors.initials: A
authors.lastname: Kutup
authors.forename: Michael F
authors.initials: MF
authors.lastname: Nentwich
authors.forename: Elfriede
authors.initials: E
authors.lastname: Bollschweiler
authors.forename: Dean
authors.initials: D
authors.lastname: Bogoevski
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.forename: Arnulf H
authors.initials: AH
authors.lastname: Hölscher
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods* / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013908:Thoracotomy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome