Transhiatal Resection Research Articles

Clinical outcome of patients with Type II gastroesophageal junction adenocarcinoma (GEJA) undergoing radical resection transthoracic or transhiatal

Objective To compare the clinical outcomes of patients with Type II gastroesophageal junction adenocarcinoma undergoing radical resection transthoracic or transhiatal. Method 198 patients with Type II GEJA were selected from Mar. 2003 to Apr. 2008. 108 patients received transhiatal cancer resection and 90 patients received transthoracic cancer resection. General clinical characteristics, operative time, hemorrhage volume, complications, Pathological characteristics, Postoperative chemoradiotherapy, in-hospital mortality, 5-year survival were compared between two groups. Results No significant difference was found on general clinical characteristics (P>0.05) between two groups. Compared with transthoracic group, the operation time was significantly shorter in transhiatal group (P 0.05). There was no significant difference on 5-year survival rate between two groups. Conclusion In-hospital complications more frequently happened in transthoracic group. More esophagus and mediastinal lymph nodes can be removed and positive incisal margins of esophagus was less in transthoracic group, however, the 5-year survival rate was not improve. Transthoracic surgery was not recommended for patients with Type II GEJA.

The prognostic value of irradiated lung volumes on the prediction of intra-/ post-operative mortality in patients after neoadjuvant radiochemotherapy for esophageal cancer. A retrospective multicenter study.

Purpose: To assess the association between dosimetric factors of the lung and incidence of intra- and postoperative mortality among esophageal cancer (EC) patients treated with neoadjuvant radiochemotherapy (N-RCT) followed by surgery (S).Methods and Materials: Inclusion criteria were: age < 85 years, no distant metastases at the time of diagnosis, no induction chemotherapy, conformal radiotherapy, total dose ≤ 50.4 Gy, and available dose volume histogram (DVH) data. One-hundred thirty-five patients met our inclusion criteria. Median age was 62 years. N-RCT consisted of 36 - 50.4 Gy (median 45 Gy), 1.8 - 2 Gy per fraction. Concomitant chemotherapy consisted of 5-Fluoruracil (5-FU) and cisplatin in 113 patients and cisplatin and taxan-derivates in 15 patients. Seven patients received a single cytotoxic agent. In 130 patients an abdominothoracal and in 5 patients a transhiatal resection was performed. The following dosimetric parameters were generated from the total lung DVH: mean dose, V5, V10, V15, V20, V30, V40, V45 and V50. The primary endpoint was the rate of intra- and postoperative mortality (from the start of N-RCT to 60 days after surgical resection).Results: A total of ten postoperative deaths (7%) were observed: 3 within 30 days (2%) and 7 between 30 and 60 days after surgical intervention (5%); no patient died during the operation. In the univariate analysis, weight loss (≥10% in 6 months prior to diagnosis, risk ratio: 1.60, 95%CI: 0.856-2.992, p=0.043), Eastern Cooperative Oncology Group-performance status (ECOG 2 vs. 1, risk ratio: 1.931, 95%CI: 0.898-4.150, p=0.018) and postoperative pulmonary plus non-pulmonary complications (risk ratio: 2.533, 95%CI: 0.978-6.563, p=0.004) were significantly associated with postoperative mortality. There was no significant association between postoperative mortality and irradiated lung volumes. Lung V45 was the only variable which was significantly associated with higher incidence of postoperative pulmonary plus non-pulmonary complications (Exp(B): 1.285, 95%CI 1.029-1.606, p=0.027), but not with the postoperative pulmonary complications (Exp(B): 1.249, 95%CI 0.999-1.561, p=0.051).Conclusions: Irradiated lung volumes did not show relevant associations with intra- and postoperative mortality of patients treated with moderate dose (36 - 50.4 Gy) conventionally fractionated conformal radiotherapy combined with widely used radiosensitizers. Postoperative mortality was significantly associated with greater weight loss, poor performance status and development of postoperative complications, but not with treatment-related factors. Limiting the volume of lung receiving higher radiation doses appears prudent because of the observed association with risk of postoperative complications.

Diaphragmatic Hernia After Esophagectomy in 440 Patients With Long-Term Follow-Up

Postesophagectomy diaphragmatic hernia (PDH) is a recognized but severely under-reported and potentially hazardous event. Information regarding the natural course of this condition and guidelines regarding indications for reoperative intervention are lacking. In this study we aim to describe the frequency, predictors of incidence, and indications for repair. Cross-sectional imaging (computed tomography scan) from patients who underwent esophagectomy between January 2001 and December 2007 at a single center were reviewed by two radiologists blinded to previous reports and clinical outcomes. Patients with PDHwere compared with a similar cohort who did not have hernia. Patient characteristics, outcomes, and hernia descriptors including longitudinal progression were recorded. Multivariable logistic regression analyses identified predictors of PDH and need for repair. Of a total of 440 patients who underwent esophagectomy, 67 (15%) were radiologically diagnosed with PDH. Of these, only 7 of 67 cases (10%) were prospectively reported by the radiologist. Median time interval from esophagectomy to hernia was 2 years. Type of esophagectomy was an independent predictor for hernia developing (p= 0.027). Patients with high body mass index were less prone to have PDH (p= 0.043). Thus far, 9 patients (2%) have required surgical intervention, all for hernia-related symptoms or progression. Despite mesh repair, 4 of 9 have recurred and 2 were re-repaired. There was 1 PDH-associated death, 8 years after transhiatal resection. Variables contributing to PDH are bothtechnical and patient dependent. Whereas the majority of patients with PDH have not required repair, a small portion who became symptomatic or had large, progressive hernia required remedial surgery. Postesophagectomy patients require long-term surveillance for PDH.

Extended Lymphadenectomy in Esophageal Cancer is Crucial

Surgery with lymphadenectomy remains the mainstay of treatment for esophageal cancer. The optimal extent of nodal dissection is controversial. Evidence is accumulating, however, that could demonstrate the benefits of extended lymphadenectomy, which include more accurate disease staging, better locoregional disease control, and improved survival. Except in very early disease where nodal metastases are rare, extended lymphadenectomy is indicated. Data from a randomized controlled trial comparing transhiatal and transthoracic resection have shown better survival in patients with limited nodal burden. Other investigations on en bloc resection, three-field lymphadenectomy, and large-scale international collaborative studies have all provided evidence for the more extensive approach to enhance cure for esophageal cancer. The more extended surgery does lead to potentially higher morbidity rates, and thus surgeons should be versatile in applying such techniques in carefully selected patients, so that postoperative survival and quality of life of patients are not compromised. The challenge in the future is how to tailor surgical strategies for individual patients in order to achieve the best outcome.

A NSQIP comparison of modern multicenter results for transhiatial versus transthoracic esophagectomy.

68 Background: The surgical approach to esophageal cancer continues to be controversial. A transthoracic approach is often advocated for better oncologic staging and improved survival. A transhiatal approach is often preferred due to a perceived decreased operative morbidity and mortality. Methods: Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-use file, patients were identified who underwent esophagectomy for cancer at the 240 participating hospitals from 2005-2011. Demographic, clinical, intra-operative variables and 30-day morbidity and mortality were collected. Results: Of the 1108 patients that had esophagectomy, 649 (58.5%) had a transhiatal (TH) resection and 459 (41.4%) had a transthoracic (TT) resection. There were no significant differences in age, gender, comorbid conditions, preoperative chemotherapy or radiation, or ASA class. Operative time was greater in the TT group (360.4 vs. 298.4min, p=0.0001). Thirty day overall mortality (TH=3.4%, TT=4.5%, p=0.3) and mean hospital length of stay(TH=15.25, TT=16.76, p=0.08) were not significantly different. The TH group had a significantly higher superficial wound infection rate (13% vs. 7.4%, p=0.002). The TT group had significantly higher rate of perioperative transfusion (9% vs. 5.1%, p=0.023) and septic shock (12.2% vs. 7.1%, p=0.004). On multivariate analysis, history of congestive heart failure and pneumonia were significant predictors of 30 day mortality. Diabetes, metabolic syndrome and COPD were predictors of morbidity. There were no differences in the rates of pneumonia, need for reintubation, ventilator requirements, or need for reoperation in both groups. Conclusions: In this modern series of patients, utilizing standardized national data collection tools, there was no significant difference in mortality of esophagectomy between transthoracic and transhiatal approaches. However, morbidity rates do vary with an increased rate of substantial morbidity in the transthoracic group including septic shock.

Surgery of esophageal cancer

Surgery is the only option for curative treatment in patients with esophageal carcinoma. Despite the debates related to the peri-operative therapy regime, a generally accepted consensus on surgical approach is not reached yet. The debate focuses mainly on pros and cons between radical transthoracic resection and the (limited) transhiatal resection in the last decade. The PubMed database was searched for randomized trials, meta-analyses, and retrospective single-center studies. The search terms were "esophageal carcinoma," "esophageal junction carcinomas," "transhiatal," "transthoracic," "morbidity," "mortality," and "surgery." The radical transthoracic approach should be the standard of care for esophageal carcinoma since it does not go along with an increased risk of postoperative morbidity or mortality but reveals an improved survival. Patient-related co-morbidities are the most influencing factors for the postoperative outcome. For type II esophageal junction carcinoma, treatment options from transhiatal extended gastrectomy to esophagectomy with hemigastrectomy or esophagogastrectomy with colonic interposition are existing. In type III esophagogastric junction carcinomas, the transhiatal extended gastrectomy is the standard of care, and the minimally invasive approach should be performed in specialized centers. Based on current available study results, this expert review provides a decision support for the best surgical strategy depending on tumor localization and patients' characteristics.

Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience

Esophageal epiphrenic diverticula are uncommon. Traditionally, thoracotomy has been the preferred surgical approach. Recently, minimally invasive approaches have been reported in a few series. However, the best surgical approach remains uncertain. In this study, we review the results of 25 articles discussing laparoscopic or thoracoscopic surgery. From January 1995 to December 2008, there were a total of 133 patients reported in English-language journals in PubMed. Nineteen patients (14 %) underwent thoracoscopic surgery, 112 (84 %) laparoscopic surgery and two patients (2 %) were treated using a combination approach. The diverticulectomy was performed using an endostapler device in all patients. A myotomy was added in 103 patients (83 %). A fundoplication was added in 106 patients (85 %). There were two deaths during surgery (2 %). The post-operative morbidity rate was 21 %. The most severe complication was suture-line leakage, which occurred in 20 patients (15 %). Recently, we successfully treated a patient with an epiphrenic esophageal diverticulum by performing a minimally invasive laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication after observing its enlargement on radiological and endoscopic examinations over 2 years. We believe laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication may therefore become the standard treatment modality for minimally invasive surgery for esophageal epiphrenic diverticulum.

Laparoscopic Transhiatal Resection for Siewert Type II Adenocarcinoma of the Esophagogastric Junction

Laparoscopic distal gastrectomy has gained wide acceptance, and laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG) are now also performed for gastric cancer. We extended these techniques to treat Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Ten patients with clinical T1 AEG type II underwent laparoscopic transhiatal (LTH) resection combined with LTG reconstructed by Roux-en-Y (LTH+LTG: n=2) or LPG reconstructed by jejunal interposition (LTH+LPG: n=8). Intracorporeal esophagojejunostomy was performed using a circular stapler, of which the anvil head was introduced transabdominally or transorally. The median operation time was 243 minutes, and blood loss was 25.5 g. There were no intraoperative complications or conversion to open surgery. No anastomotic leak was observed, but 1 diaphragmatic herniation to the left thoracic cavity occurred postoperatively. The median length of the proximal margin was 14.5 mm. This operation is technically feasible and can be safely performed after adequate experience of LTG or LPG, though esophagojejunostomy in the mediastinum is technically demanding.

Surgical management of benign strictures of the oesophagus: 18 years of experience

Introduction: Benign strictures of the oesophagus are not uncommon. The majority are due to ingestion of corrosives. Different forms of therapy have been recommended. Repeated stricture dilatation has been advocated; when this fails surgical replacement of the oesophagus may be required. There is little information regarding oesophageal dilatation in Sri Lanka. Aim: To retrospectively analyze an 18 year series of patients with benign strictures of the oesophagus treated in a single surgical unit to determine the safety and long term effectiveness of oesophageal replacement by a variety of techniques. Methods: 110 Patients with benign strictures of the oesophagus were treated in a single surgical unit at the Sri Jayawardenapura General Hospital, Nugegoda, Sri Lanka from 1994 to 2011. Clinical, pathological and operative data were reviewed from medical records and interviews with patients and relatives. Results: The male: female ratio was 1.14. Caustic soda ingestion was the commonest cause. Ninety two patients had undergone dilatation prior to presentation without improvement of dysphagia, while 65 had other procedures performed. Transhiatal resection of the oesophagus was the preferred method. Gastric transposition was performed in 67 while the colon was used as the conduit in the others. Recurrence of dysphagia was seen in 8 (7.6%) while the operative mortality rate was 5.4% Conclusion: Surgical treatment of benign strictures of the oesophagus by oesophageal replacement with the stomach or colon is a good option in patients with strictures that do not respond to dilatation and can be carried out with low mortality and morbidity. Repeated attempts at dilatation are unwarranted in such patients. DOI: http://dx.doi.org/10.4038/sljs.v30i1.4502 The Sri Lanka Journal of Surgery 2012; 30(1):18-25

PTU-168 2-Stage oesophagectomy confers no survival advantage over transhiatal resection: analysis of 550 consecutive cases in a single unit

IntroductionThe optimal operative approach to resectable cancers of the oesophagus and oesophago-gastric junction is contentious. Both transhiatal (THO) and 2-stage (2-ST) resections are routinely practised in our unit, largely according...

OC-124 Centralisation of OG services in the west of Scotland: are we matching the outcomes of the UK national OG audit?

IntroductionThe SAGOC report (1997–2000) highlighted the high morbidity and mortality of oesophageal and gastric resections in Scotland. Since then, centralisation into higher volume units has only slowly occurred in Scotland....

Laparoscopic Transhiatal Approach for Resection of Midesophageal Diverticula

Resection of symptomatic midesophageal diverticula is traditionally performed with a thoracic approach, occasionally requiring additional laparoscopic surgery for management of associated pathologies, such as esophageal dysmotility and hiatus hernia. We present the resection of large midesophageal pulsion diverticula using a single laparoscopic transhiatal approach. Bariatric instrumentation was used to obtain extra intraoperative length, and concurrent on-table endoscopy was performed to ensure complete mucosal seal. The patient was discharged home on day 19 and remains well 12 months after surgery. Laparoscopic transhiatal resection of symptomatic midesophageal diverticula may be a safe alternative to the traditional thoracic or thoracoabdominal technique.

Outcome Following Surgical Management of Corrosive Strictures of the Esophagus

To analyze the short- and long-term outcomes following surgical treatment for corrosive stricture of the esophagus. Surgery is a well-established treatment for corrosive strictures of the esophagus and involves either resection or bypass of the damaged esophagus and replacement by a conduit. The need for resection and the choice of the ideal conduit for esophageal replacement in these patients continues to be debated and there are only a few studies reporting on the long-term outcome following the surgical treatment. This was a retrospective analysis of patients with corrosive stricture of the esophagus who were managed surgically between 1983 and 2009. The type of surgery performed (resection or bypass), the conduit used, the short- and long-term outcomes were assessed. One hundred seventy-six corrosive strictures of the esophagus were managed surgically (resection: 64, bypass: 112). A transhiatal resection could be accomplished in 59 of 62 patients in whom it was attempted. Stomach conduits were used in 107 patients and colonic conduits in 69. The mean operating time was 4.3 ± 1.5 hours and the mean estimated blood loss 592 ± 386 mL. Cervical anastomotic leak occurred in 22 patients (12.5%). Follow up of more than 10 years was available for 78 patients (44.3%) and more than 15 years for 54 patients (30.7%). Recurrent dysphagia developed in 33 patients (18.7%). There were no differences in the short- or long-term outcomes in patients who underwent resection or bypass. The mean duration of surgery, intraoperative blood loss, incidence of conduit necrosis, and in-hospital mortality was significantly lower in patients with stomach conduits as compared with colonic conduits. There was a higher incidence of recurrent laryngeal nerve palsy, recurrent dysphagia, and aspiration after surgery in patients with strictures involving the upper end of the esophagus at or near the hypopharynx. Satisfactory outcomes are achieved after surgery for corrosive strictures of the esophagus. Resection of scarred esophagus may be done without a substantial increase in the morbidity and mortality; however, the outcomes are not significantly different from bypass. Stomach is a good conduit and the colon should be reserved for cases where the stomach is not available. Long-term outcomes in patients with hypopharyngeal strictures, however, continue to be poor.

Curative treatment of oesophageal carcinoma: current options and future developments

Since the 1980s major advances in surgery, radiotherapy and chemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment.The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. In recent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery alone is poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging and endoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved.

Ileocecectomy for Crohn's Disease (CD): Which Factors Augment Intraoperative Small Bowel Preservation?

Objective: The role of surgical therapy in patients with locally advanced esophageal cancer is still controversially discussed. There is also controversy about whether neoadjuvant chemo or radio-chemotherapy should be the standard management in patients with locally advanced esophageal carcinoma. Furthermore, many gastroenterologists and oncologists believe that surgery should be avoided in locally advanced esophageal cancer due to high mortality and morbidity rates related to the procedure and the very low benefit for the patient. Material and Methods: Retrospective analysis of prospectively collected data of 256 patients with locally advanced esophageal cancer (220 patients with pT3 and 36 patients with pT4) that were not neoadjuvantly treated and had surgical resection with curative intend. One-hundred-sixty-one patients underwent extensive Ivor-Lewis thoracoabdominal esophagectomy (TAE) whereas 95 had limited transhiatal (TH) resection. Locally advanced esophageal cancer was defined, based on the final histological report of the resection specimen, as a tumor infiltrating the paraesophageal tissue or the adjacent structures, without respect of the lymph node affection, the distant metastases or the histological grading. Results: Complete resection (R0) was achieved in 74.5% of patients that underwent TA esophagectomy and in 61.1% of the patients with TH resection (p=0.016). The median lymph node yield in TAE was significantly higher (25 lymph nodes, range 2-89) than in patients operated TH (14 LN, range 2-100; p=0.008), although no benefit for overall survival was found for patients with radical lymphadenectomy (lymph node yield of 19 or more median 9 months vs. lymph node yield of 18 or less median 10.8 months; p=0.480). Patients with locally advanced esophageal cancer but without evidence of tumor rest disease (pT3 & pM0 & R0, irrespective of the lymph node status) had similar overall survival (median 23.7 months, 5-Y of 22.4%) as pT2 without evidence of tumor rest disease (median 33 months, 5-Y of 27%; p=0.152). The operative method had significant influence on the disease free survival (TAE-median 12.1 months, 5-Y 22.9%; or TH median 10 months, 5-Y 8.9%; p=0.049, data not shown). Discussion: Our results in the treatment of the patients with locally advanced esophageal carcinoma (median 13.7 months, 5-Y of 14.4%) are comparable to the results of the patients neoadjuvantly treated with chemoradiotherapy (median 10 to 14 months; 5-Y of 19-23%).

Place de la chirurgie dans le traitement des cancers superficiels sur endobrachyœsophage

The indication of surgical resection for early cancer in Barrett's esophagus is based on the risk of lymph node extension, which is conditioned by the depth of the lesions. Even if the high resolution endosonography is more sensitive than conventional endosonography for differentiating mucosal from submucosal lesions, it may be lacking for intermediate lesions (m3 and sm1). Macroscopic criteria are useful for identifying high-risk lesions. In contentious cases, endoscopic resection may be considered as a biopsy to determine the further treatment. The endoscopic resection is indicated for mucosal lesions in selected patients. Surgery remains the standard treatment for early cancer in Barrett's esophagus. The transhiatal resection is indicated for high-risk T1a mucosal lesions. The transthoracic resection is indicated for submucosal lesions.

How Radical Should Surgery Be for Early Esophageal Cancer?

We have compared the oncologic effectiveness of limited resection (LR) techniques such as transhiatal (TH) or limited resection of the esophagogastric junction with intestinal interposition (LREGJ) in the treatment of early esophageal carcinoma with that of the extended resection such as the classical thoracoabdominal (TA) en bloc esophagectomy. We performed a retrospective analysis of prospectively collected data of 113 patients with T1 esophageal cancer (57 adeno- and 56 squamous cell carcinomas) who had surgical resection with systematic lymphadenectomy. Forty-one underwent extensive (TA) and 72 limited resection (51 TH and 21 LREGJ). Complete resection (R0) was achieved in all cases. Lymphatic metastases were seen in none of the mucosal but in 26.8% of the submucosal T1 cancers. The median lymph node yield was significantly higher in patients with extensive resection (24 vs. 15 lymph nodes; p=0.036), but this did not affect the overall survival (median=88 vs. 102 months, 5-year survival probability=57.8 vs. 67.7%; log rank=0.578). The median hospital stay and ICU stay were significantly shorter in the LR group (p=0.039 and p = 0.044, respectively). Limited resection leads to lower lymph node yield but similar oncologic effectiveness as the extensive surgery. It may represent a valuable alternative in the treatment of patients with early (submucosal) esophageal carcinoma.

Esophageal Cancer Surgery in Patients Older than 75: Long Term Results

Purpose : The purpose of this study was to evaluate short and long term results after esophageal cancer resection in patients older than 75.Methods : We retrospectively analyzed the database of esophageal cancer surgically treated in our department between January 2003 and December 2009 to identify patients older than 75. The preoperative, operative, postoperative and long term characteristics were analyzed.Results : Among 137 patient, 23 were older than 75. The histological subtype was adenocarcinoma in 100%. The surgical techniques were a “Lewis-Santy” procedure in 43%, a trans-hiatal resection in 22%, a “Sweet” procedure in 13%, a stripping in 13% and a McKeown procedure in 9%. The in-hospital postoperative mortality was 13%. The in-hospital postoperative morbidity (Dindo-Clavien Grade > 2, deceased patients included) was 26%. In univariate analysis, no statistically significant risk factor of morbidity was found. A Charlson Comorbidity Index > 2 was, in univariate analysis, the sole risk factor of postoperative mortality (p = 0.0362). The mean hospital stay was 22 ± 12 days. The median survival was 24.2 months. The 5-year overall survival was 39% and the 5-year disease free survival was 26%. 57% of long-term deaths were not cancer related.Conclusion : Esophageal surgery performed in selected patients older than 75 has an acceptable morbidity and mortality but when a severe complication occurs, it leads to death in half of the cases. Surgery enables a long term survival benefit. This study confirmed our attitude of not considering age as a contra-indication for esophageal surgery but rather considering general status, self-reliance and associated comorbidities for patients’ selection.

Management and Outcome of Intrathoracic Bleeding due to Vascular Injury During Transhiatal Esophagectomy

Study ObjectiveThe objective of this study was to ascertain the incidence and outcome of intrathoracic vascular injury during transhiatal resection of the esophagus. BackgroundResection of the esophagus is indicated for a variety of benign and malignant diseases and can be performed via the transhiatal or transthoracic route. As the esophagus is in close vicinity to the aorta, pulmonary vessels and the azygous vein, these blood vessels can be injured during its resection. MethodsWe extracted data on the incidence, management, and outcome of intrathoracic vascular injuries that occurred during transhiatal esophagectomy between 1983 and 2010 from a prospectively maintained esophageal diseases database. ResultsDuring this period, 710 transhiatal esophagectomies were done for malignant (n = 617) and benign causes (n = 93). Intrathoracic vascular injury occurred in ten patients (1.4%). The indication for esophagectomy was malignancy (nine patients) and corrosive stricture (one patient). All nine patients with malignancy had squamous cell carcinoma, and the tumor was located in the midthoracic esophagus in seven and lower thoracic esophagus in two patients. Eight of nine patients with cancer had received preoperative radiotherapy. The site of injury was the aorta/its esophageal branch (six patients), azygous vein (three patients), and inferior pulmonary vein (one patient). The estimated median intraoperative blood loss was 4,450 ml (range, 2,000–6,000 ml), and the median duration of the surgery was 5 h (range, 4–7 h). On a multivariable analysis, location of tumor (in the midthoracic esophagus) was a significant risk factor for the occurrence of vascular injury. Seven patients required a thoracotomy to control the bleeding while in two patients, it could be identified and controlled transhiatally. Two patients died intraoperatively due to massive bleeding and another two died in the postoperative period. Of the patients who survived (n = 6), three patients had an uneventful recovery, one patient developed a cervical anastomotic leak, and two patients developed chest infection. ConclusionVascular injury during transhiatal esophagectomy is a rare but life-threatening complication. There may be a higher risk in tumors located in the mid esophagus. Management involves prompt identification and control via a dilated hiatus or a thoracotomy.

Esophagectomy for cancer in octogenarians

Because of changes in life expectancy, there is an increasing number of elderly patients with esophageal cancer. The aim of this study was to assess the outcome of esophagectomy for cancer in patients 80 years or older. A retrospective review was performed of the records of all patients who underwent esophagectomy for cancer from 1992 to 2007. A cardiac and pulmonary evaluation was obtained on an individual basis in the younger patients and in all octogenarians. Among 560 patients with esophagectomy for cancer, 47 patients (8%) were octogenarians. The median age of the younger group (n= 513) was 63 years (interquartile range 56-71). Octogenarians had significantly more stage III disease (49% vs 31%, P= 0.02) but received less neoadjuvant therapy than younger patients (2% vs 21%, P= 0.0004). In octogenarians, the transhiatal resection was more common than in the younger group (79% vs 36%, P < 0.0001). Weight loss prior to surgery was similar in both groups, but body mass index was significantly lower in octogenarians (25 vs 28 kg/m(2) , P= 0.0002). Major complications occurred in 26% in octogenarians and 31% in the younger group (P= 0.51). Hospital mortality was similar (9% for octogenarians vs 4% in the younger group, P= 0.13). The median postoperative hospital stay was similar at 16 days (P= 0.69). There was no difference in cancer-related survival (median survival 48.9 vs 59.3 months, P= 0.31 log-rank test). Esophagectomy can be performed safely in carefully selected octogenarians with good cardiac and pulmonary function. Patients should not be denied an esophagectomy based only on their age.