Transhiatal esophagectomy was championed by American Dr. Orringer since 1976. The issues were: inadequate field exposure; inadequacy of node clearance, use of blind & blunt dissection & (rarely) azygos vein tear. Benefits: avoiding thoracotomy and all the morbidity associated with it.
So, what is the current opinion?
Attached is a link to a comparative study.
http://www.sages.org/meetings/annual-meeting/abstracts-archive/a-comparison-of-laparoscopic-transhiatal-esophagectomy-without-thoracoscopic-port-versus-open-transhiatal-esophagectomy/
Dr. Gelder,
Thanks for that. But I wanted to know the current status of transhiatal esophagectomy itself, not comparison between open & laparoscopy.
Dear Dr. Rangarajan,
I think you will find different answer from different surgeons and different answers at different institutions. You are quite familiar with the transmittal esophagectomy a procedure I have not performed. As part of the surgical team for the Departments of Surgery and Pathology at Louisiana State University Medical School my job involved evaluations for metastatic disease, risk analysis including age, bone marrow function, immune function, nutritional status and general health. I made decisions for mitigating risk to the patient and measured quality of life post procedure as one of the most important outcomes in making therapeutic decisions. Many would argue that if this specific procedure is not preformed for cure other (though not necessarily better but less invasive) options are available. I personally would consent to the transmittal esophagectomy procedure pending the absence of metastatic disease at workup and that my surgeon of choice for the procedure was skilled in the procedure and had several under his belt. I hope you find the answer your are looking for and if you do I would like to know your final conclusion. Also as I read between the lines of your question it may be that you have your own opinion and possibly some improved techniques for managing such a difficult procedure. I am interested in knowing if you have developed a newer more creative surgical approach to this very difficult problem.
Best to you.
Thanks very much for taking the time to write this, I can see your (very experienced) point of view.
In our center, we used to follow laparoscopic transhiatal esophagectomy for lower third squamous cancer & failed myotomy for achalasia cardia. But for the last 10 years, we follow thoraco-laparoscopic resections with patients placed in the prone position.
Please read chapters 25 & 26 of our Textbook:
http://books.google.co.in/books?id=Tc9SDx5pXjIC&pg=PA394&lpg=PA394&dq=thoraco--laparoscopic+esophagectomy+AND+palanivelu&source=bl&ots=BxGWKYlNsI&sig=xFI4ncWFfXY_Xsm1QD1a1qiF7Og&hl=en&sa=X&ei=BDUwU5KIJImLrQfe_YEg&ved=0CEgQ6AEwBA#v=onepage&q=thoraco--laparoscopic%20esophagectomy%20AND%20palanivelu&f=false
Thank you for the link to for the chapters from your book. I will read this new information and approach to to surgical intervention with great interest. Best to you.
Thank you for for very good debate,we have been doing oesophageal surgery for last one decade and transhiatal approach have been used in around 100 patients,both for benign and malignant stricture .for corrosive stricture which is fairly common in young ladies we found it curative with good results .Malignant stricture unfortunately have late presentation and this technique is useful palliative procedure especially involving the lower end of oesophagus.i would like to know comments of other friends,we generally do pylromotomy,what is opinion of other friends?
Thanks for sharing your wide experience Dr. Gondal. I agree with your protocol, we follow the same . We always add a pyloromyotomy as well
This good debate and morbidity is less as compared to conventional Ivor Lewis .
Dear dr Rangarajan,thank you for your comments,what is your experience about anastomoses leakage ,we had this in about 5to6percent of cases,and all settled on conservative treatment ,parentral nutrition for one to two weeks,
Thank you dr Rangarajan ,yes as the anastomoses in transhiatal procedures is in the neck, may I know the percentage of leak and post op stricture as we had few cases which needed post op dilatation,
We follow thoraco-laparoscopic resections for lower third squamous cancer,but not a few cases.we can know the new information and approach for esophagectomy .
Dear Dr. Fenglin, thanks for your input.
Our current policy:
We too follow thoraco-laparoscopic esophagogastrectomy with 2-field node dissection for squamous carcinoma. For adenocarcinoma of OG junction we prefer thoraco-laparoscopic proximal gastrectomy+ partial esophagectomy + thoracic anastomosis. In our center, laparoscopic transhiatal esophagectomy is done only for benign conditions like sigmoid esophagus after failed cardiomyotomy
Transhiatal oesophagectomy is a very useful procedure for treatment of oesophageal cancer. Apart from Orringer we have a large experience if this technique published in the BJS “surgical resection strategy ....“
It is best used for early tumours of the lower oesophagus only when the tumour can be fully dissected undwr direct vision and when obvious disease is not being left behind (pointless surgery otherwise). whilst trans thoracic surgery may have advantages in terms of node yield and maybe margin rates there is very little wvidence that this translates into a survival adva
....Advantage
My only comment on squamous cancers is that because of their high propensity for nodal spread up the mediastinal chain that this makes them relatively unsuitable for TH orsophagectomy other than the fact that if combined with neo adjuvant chemo or chemorad that the disease may already have responded. We do have a series of squamous cancers with very acceptable outcomes after THO (45% 5YS)
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