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TRANSHIATAL VERSUS TRANSTHORACIC ESOPHAGECTOMY: THE INFLUENCE OF ONE-LUNG VENTILATION ON POSTOPERATIVE PULMONARY COMPLICATIONS, LYMPH NODE YIELD AND OVERALL SURVIVAL
Jasmin Trachsel
2, Sarah Gerber
1, Pauline Aeschbacher
1, Dino Kröll
1, Yves Borbély
*11Inselspital Universitatsspital Bern, Bern, BE, Switzerland; 2Inselspital Universitatsspital Bern, Bern, BE, Switzerland
Background
Surgical resection is the mainstay of a curative treatment approach for advanced, localized esophageal cancer. However, esophagectomy (EE) carries a significant morbidity. Pulmonary complications are main contributors, and one-lung ventilation (OLV) as a causative factor is debated. Transhiatal approaches are thought to mitigate this risk, but may compromise lymph node removal.
This study compares the outcomes of two approaches of EE with the same extent of resection and cervical anastomosis; minimally invasive transthoracic esophagectomy with (MIE) and open transhiatal esophagectomy (THE) without OLV, focusing on pulmonary complications and stage-specific survival.
Methods
We retrospectively analyzed all patients undergoing MIE-McKeown-EE and THE after preoperative radiochemotherapy between 01/2001 and 12/2022 at a tertiary University Hospital. Patient data were extracted from prospectively recorded electronic medical files. Overall and disease-free survival were calculated using Kaplan-Meier survival analysis. Differences between groups were assessed using appropriate statistical tests, such as the Mann-Whitney U test for continuous variables and the Fisher's exact test for categorical variables.
Results
Of 200 included patients, 73 (36.5%) underwent MIE and 127 (63.5%) THE. Patients undergoing MIE had higher American Society of Anesthesiologists scores than THE (ASA III 78.1% vs 61.4%; ASA IV 13.7& vs 6.3%; p=0.01) and restrictive pulmonary disease (12.7 % vs 0%, p=0.01). Patients in the MIE-group had higher ASA scores and advanced cancer stages.
In the MIE group, 12 patients (16.4%) had pneumonia, in the THE group 34 (26.8%, p=0.95). Mean number of lymph nodes removed during MIE were 26.2 ± 13.0, and 26.5 ± 13.0 in THE (p=0.892). In patients with chronic obstructive pulmonary disease, pneumonia rate was 25% in MIE (2 of 8) and 41% (9 of 22) THE patients.
Stage IV patients with MIE had a better 2-year survival rate (66.7% vs. 34.8%, p=0.35), whereas survival of stage II patients was better after THE (75% vs. 100%, p=0.30). No significant differences were observed for stage III patients.
Conclusion
In patients with esophagectomy after radiochemotherapy, MIE with OLV resulted in fewer pulmonary complications than in THE without OLV, despite higher ASA scores.
Lymph node yield was similar in both techniques. Yet, patients with more advanced cancer stages had better overall survival after MIE than after THE.
These data could not justify the assumption that transhiatal esophagectomy without one-lung ventilation does reduce pulmonary complications.
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