Abstracts
1997 Digestive Disease Week

Transhiatal esophageal resection versus transthoracic esophageal resection with two-fields lymphadenectomy: interim results of a randomized study.

JW van Sandick*, JJB van Lanschot*, EJ Spillenaar Bilgen§, HG Gooszen#, H. Obertop*. Departments of Surgery, *Academic Medical Center Amsterdam, §Academic Hospital Dijkzigt Rotterdam, and #Academic Hospital Utrecht, The Netherlands.

Long-term prognosis after a potentially curative resection for esophageal cancer is still poor. Non-randomized studies suggest that extensive lymphadenectomy in addition to wide local excison of the primary tumor provide a beneficial effect on 5-year survival, although the procedure is possibly associated with a high risk of postoperative complications.

A randomized multicenter trial has been initiated comparing two different surgical treatment modalities for patients with a potentially curable adenocarcinoma of the esophagus and/or GE-junction, i.e. transhiatal esophagectomy without thoracotomy (THE) versus transthoracic esophagectomy with two-fields lymph node dissection (TTE). The aim of this interim analysis was (1) to evaluate the occurrence of postoperative complications in both groups and (2) to assess a quality control on the extended lymph node dissection. Between April 1994 and November 1996, 80 patients were randomized. Data analysis was based on the intention to treat principle. The two groups were comparable regarding age, sex, ASA-classification, tumor localization and pathological stage.

Results:

                              THE            TTE          p value* 

Number of patients             38             42
Median ICU-stay (range)         2.5 (0-21)     6 (0-35)   0.0005
Median hospital stay (range)   15   (8-53)    22 (7-117)  0.0002
In-hospital mortality           0   (0%)       3 (7%)     ns
Pulmonary complications         8   (21%)     26 (62%)    0.0002
Chylothorax                     1   (3%)       5 (12%)    ns
Clinical leakage                3   (8%)       2 (5%)     ns
Median number of resected
  lymph nodes (range)          15 (4-40) 28 (5-56) 0.0001

   *Mann-Whitney U test, chi-square or Fisher's exact test when appropriate.

Conclusion: Transthoracic esophageal resection is associated with increased postoperative morbidity, as compared to the transhiatal resection. Furthermore, this interim analysis indicates that an adequate extended lymph node dissection has been achieved. We conclude that continuation of this trial with careful monitoring is justified in order to answer the question whether the extended thoracic resection sufficiently improves long-term survival to compensate for the increase in postoperative morbidity.