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Background: Controversy persists as to the preferred operative approach to esophageal cancer. Therefore, we investigated the peri-operative, short-term, and mid-term outcomes between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) at our institution.

Methods: We conducted a retrospective review of 114 patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those patients who underwent THE or TTE we compared: a) clinical characteristics; b) pathologic findings; and c) outcomes. Parametric and non-parametric tests of significance were performed, and survival was determined by Kaplan-Meier analysis.

Results: We identified 32 patients who underwent THE, and 82 patients who underwent TTE. Age, gender, race/ethnicity, alcohol and tobacco use, weight loss and body mass index at the time of surgery, operative risk, chemoradiation regimen, tumor stage, and pathologic findings were similar between groups. Those who underwent THE had a greater intra-operative blood loss (p=0.003), required more intra-operative blood transfusions (p<0.0001), spent a longer time on the ventilator (p<0.0001) and in the intensive care unit (p=0.002), and had a higher 30-day mortality (p=0.023). Likewise, those who underwent THE had a greater prevalence of post-operative vocal cord dysfunction (17% vs 3%, p=0.027) and anastomotic leak (29% vs. 1%, p<0.0001). Compared to THE, patients undergoing TTE had a greater number of lymph nodes sampled (mean 13.0 vs 13.6, respectively) and frequency of lymph nodes positive for carcinoma (29% vs 35%, respectively). Finally, survival at 3-years was significantly less after THE than after TTE (26% vs. 53%, p=0.035), as was overall 5-year survival (p=0.039) (Figure 1).

Conclusions: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach.