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J Thorac Cardiovasc Surg 2003;125:1114-1120
© 2003 The American Association for Thoracic Surgery

General Thoracic Surgery

Transthoracic versus transhiatal esophagectomy: A prospective study of 945 patients

From the Veterans Affairs Medical Center/University of Utah Medical School, Salt Lake City, Utah^a; the Veterans Affairs Medical Center/Duke University Medical School, Durham NC^b; the Institute for Health Policy, Massachusetts General Hospital/Partners Healthcare System; Department of Medicine, Harvard Medical School, Boston Mass^c; the Veterans Affairs Medical Center/Harvard Medical School, Brockton/West Roxbury, Mass^d; and the Cooperative Studies Program Coordinating Center, Veterans Affairs Medical Center, Hines, Ill.^e

Read at the Twenty-eighth Annual Meeting of The Western Thoracic Surgical Association, Big Sky, Mont, June 19-22, 2002.

Received for publication July 10, 2002. Revisions requested Aug 26, 2002; revisions received Sept 10, 2002. Accepted for publication Sept 17, 2002. Address for reprints: David Bull, MD, Division of Cardiothoracic Surgery, University of Utah Health Sciences Center, 30 North 1900 East, Salt Lake City, UT 84132-2301 (E-mail: David.Bull{at}hsc.utah.edu).

Objective: Debate continues as to whether transhiatal esophagectomy results in lower morbidity and mortality than transthoracic esophagectomy. Most data addressing this issue are derived from single-institution studies. To investigate this question from a nationwide multicenter perspective, we used the Veterans Administration National Surgical Quality Improvement Program to prospectively analyze risk factors for morbidity and mortality in patients undergoing transthoracic esophagectomy or transhiatal esophagectomy from 1991 to 2000.
Methods: Univariate and multivariate analyses were performed on 945 patients (mean age, 63 ± 10 years). There were 562 transthoracic esophagectomies and 383 transhiatal esophagectomies in 105 hospitals, with complete 30-day outcomes recorded.
Results: There were no differences in recorded preoperative variables between the groups that might bias any comparisons. Overall mortality was 10.0% (56/562) for transthoracic esophagectomy and 9.9% (38/383) for transhiatal esophagectomy (P = .983). Morbidity occurred in 47% (266/562) of patients after transthoracic esophagectomy and in 49% (188/383) of patients after transhiatal esophagectomy (P = .596). Risk factors for mortality common to both groups included a serum albumin value of less than 3.5 g/dL, age greater than 65 years, and blood transfusion of greater than 4 units (P < .05). When comparing transthoracic esophagectomy with transhiatal esophagectomy, there was no difference in the incidence of respiratory failure, renal failure, bleeding, infection, sepsis, anastomotic complications, or mediastinitis. Wound dehiscence occurred in 5% (18/383) of patients undergoing transhiatal esophagectomy and only 2% (12/562) of patients undergoing transthoracic esophagectomy (P = .036).
Conclusions: These data demonstrate no significant differences in preoperative variables and postoperative mortality or morbidity between transthoracic esophagectomy and transhiatal esophagectomy on the basis of a 10-year, prospective, multi-institutional, nationwide study.

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