P46 TRANSTHORACIC VERSUS TRANSHIATAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATION-WIDE PROPENSITY SCORE MATCHED COHORT ANALYSIS

Abstract

Abstract Aim The current study aims to compare transthoracic and transhiatal esophagectomy in a propensity score matched nation-wide cohort study. Background & Methods Chemoradiotherapy followed by resection is the standard therapy for resectable esophageal carcinoma in the Netherlands. The optimal surgical approach remains a matter of debate. Data was acquired from the Dutch Upper-GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma from 2011-2016 were included. Patients with missing baseline data and patients undergoing emergency or hybrid surgery were excluded. Patients who underwent a transthoracic (TTE) or transhiatal (THE) esophagectomy were compared after propensity score matching. Results After propensity score matching, 1532 patients were included for analysis. The transthoracic approach yielded more lymph nodes (median 19 vs 14; p<0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher after TTE (p=0.044). The TTE group experienced more chyle leakage (9.7% vs 2.7%, p<0.001) and more pulmonary (35.5% vs 26.1%, p<0.001) and cardiac complications (15.4% vs 10.3%, p=0.003). The TTE group required a longer hospital stay (median 14 vs 11 days, p<0.001), ICU stay (median 3 vs 1 day, p<0.001) and had a higher early mortality rate (4.0% vs 1.7%, p=0.009). Subgroup analysis on anastomotic level showed that TTE with intrathoracic anastomosis (TTEi) had a significantly lower recurrent nerve lesion incidence (0.5%) compared to TTE with cervical anastomosis (TTEc) (7.4%, p=<0.001) and THE (5.9%, p=<0.001). There was no statistical difference in anastomotic leakage rates on anastomotic level, however incidence was lowest after TTEi (TTEc 21.5%, TTEi 15.1%, THE 19.5%). The higher early mortality rate after TTE was mainly caused by TTEc (4.6%), however, only the difference of early mortality between TTEc and THE (1.7%) reached statistical significance (p=0.006). Conclusion TTE provided a more extensive lymph node dissection which resulted in a higher N-stage, at the cost of increased morbidity and short-term mortality. Although results in high-volume centers are often superior, these data reflect nationwide results. Future research should investigate if a more extensive lymph node dissection leads to an improved long-term survival.