Chapter 87: Transhiatal Esophagectomy

INTRODUCTION

Surgery, either alone or in combination with other therapeutic options (chemotherapy and/or radiotherapy), remains an essential component of a multimodality approach to midstage esophageal cancer and an effective means to achieve a long-term disease-free state. However, despite considerable improvements in reducing the perioperative morbidity and mortality of esophageal resection, surgery alone—regardless of the approach—is inadequate to achieve a cure in the vast majority of patients.^1,2 The history of surgical resection for esophageal carcinoma has been well described by Hurt.³ The first successful resection of a cervical esophageal carcinoma was performed by Czerny in 1877. Denk followed by describing the first “pull through” operation in a cadaver that removed the esophagus without a thoracotomy in 1913. Turner further developed the technique and performed the first successful Denk-type operation on a patient in 1933. However, due to early failures, the transpleural esophageal resection became the established procedure for esophageal carcinoma until Orringer reintroduced the transhiatal Denk-Turner “pull through” operation in 1976 reporting impressive initial results—subsequently updated and validated—that mimicked those produced with the transthoracic approach.^4,5

Proponents of the transhiatal esophagectomy, transthoracic (Ivor Lewis) esophagectomy, three-field lymphadenectomy, and minimally invasive esophagectomy have described the advantages of their respective techniques despite the lack of solid evidence demonstrating a disease-free or overall survival benefit of one technique over another.^6-10 The proposed advantages of the transhiatal esophagectomy include less pulmonary complications with the avoidance of a thoracotomy, and the relatively benign nature of cervical esophagogastric anastomotic leaks leading to reduced perioperative mortality.^8,11 Initial critics of this approach were concerned about inadequate hemostasis and a compromised lymph node dissection when utilizing a “blind” mediastinal mobilization. These concerns have been allayed and the equivalent oncologic efficacy of the transhiatal approach has been consistently confirmed in recent population-based studies, meta-analyses, and one large prospective randomized phase III trial.^9,12,13 More important than the operative approach are the surgeon’s case volume, ability to individualize the procedure based on the patient’s performance status, tumor location and extent, and ability to rescue patients from life-threatening complications more effectively.¹⁴ The only contraindications to a transhiatal approach are the unusual occurrences of documented tracheobronchial invasion of an upper or middle third esophageal carcinoma or severe adherence of the esophagus to vital structures (secondary to a locally advanced tumor or from prior surgery) that is encountered during mediastinal exploration, which may preclude a safe dissection and therefore require additional exposure via a thoracotomy.

The impact and role of surgery in the setting of multimodality therapy with either neoadjuvant chemotherapy or chemoradiotherapy continue to be examined in ongoing clinical trials that attempt to improve on the historically dismal outcomes in esophageal carcinoma. With strong evidence for both improved median survival and R0 resection rates after neoadjuvant chemotherapy or chemoradiotherapy without increasing the risk of perioperative outcomes, exercising the proper surgical technique to optimize ...