title: Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison.
abstract: OBJECTIVE
  Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer.
  
  
  METHODS
  This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival.
  
  
  RESULTS
  537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75).
  
  
  CONCLUSIONS
  TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).
authors.affiliation: Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Onkar V
authors.initials: OV
authors.lastname: Khullar
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Renjian
authors.initials: R
authors.lastname: Jiang
authors.affiliation: Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
authors.affiliation: Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Allan
authors.initials: A
authors.lastname: Pickens
authors.affiliation: Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Manu S
authors.initials: MS
authors.lastname: Sancheti
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Kevin
authors.initials: K
authors.lastname: Ward
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.|Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Theresa
authors.initials: T
authors.lastname: Gillespie
authors.affiliation: Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Fernandez
mesh_terms: D000230:Adenocarcinoma / Q000191:economics / Q000401:mortality / Q000601:surgery*; D000368:Aged; D004938:Esophageal Neoplasms / Q000191:economics / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000191:economics* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D018426:SEER Program; D015996:Survival Rate; D013908:Thoracotomy / Q000191:economics* / Q000401:mortality
keywords: esophageal adenocarcinoma; esophagectomy; transhiatal esophagectomy; transthoracic esophagectomy; value