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J Thorac Cardiovasc Surg 2008;135:1228-1236
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma

^a Department of Surgery, the Keck School of Medicine, University of Southern California, Los Angeles, Calif
^b Department of Cardiothoracic Surgery, the Keck School of Medicine, University of Southern California, Los Angeles, Calif

Received for publication July 2, 2007; revisions received September 15, 2007; accepted for publication October 4, 2007.

^_* Address for reprints: Steven R. DeMeester, MD, Department of Cardiothoracic Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033. (Email: sdemeester{at}surgery.usc.edu).

Objective: Neoadjuvant therapy is commonly used for esophageal adenocarcinoma. We have reported reduced local recurrence rates and improved survival after an en bloc esophagectomy compared with a transhiatal resection as primary therapy for adenocarcinoma of the esophagus. The aim of this study was to determine whether the benefits of an en bloc resection would extend to patients after neoadjuvant therapy.

Methods: The charts of all patients with esophageal adenocarcinoma that had neoadjuvant therapy and en bloc or transhiatal esophagectomy from 1992–2005 were reviewed. Patients found to have systemic metastatic disease at the time of the operation or who had an incomplete resection were excluded.

Results: There were 58 patients: 40 had an en bloc resection and 18 had a transhiatal esophagectomy. A complete pathologic response occurred in 17 (29.3%) of 58 patients. Median follow-up was 34.1 months after en bloc resection and 18.3 months after transhiatal resection (P = .18). Overall survival at 5 years and survival in patients with residual disease after neoadjuvant therapy was significantly better with an en bloc resection (overall survival: 51% for en bloc resection and 22% for transhiatal resection [P = .04]; survival with residual disease: 48% for en bloc resection and 9% for transhiatal resection [P = .02]). Survival in patients with complete pathologic response tended to be better after an en bloc resection (en bloc, 70%; transhiatal, 43%; P = .3).

Conclusion: An en bloc resection provides a survival advantage to patients after neoadjuvant therapy compared with a transhiatal resection, particularly for those with residual disease. Similar to patients treated with primary resection, an en bloc esophagectomy is the procedure of choice after neoadjuvant therapy.

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Discussion
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