1. Background
There is a great deal of debate about whether en bloc esophagectomy provides esophageal cancer through a practical and prolonged resolution of obstruction of the esophagus. Despite higher mortality, further exacerbation, and diagnosis, a recent 7-year follow-up of a Dutch study on GEJ and lower esophageal cancers does not appear to be of any further benefit. Also, in a subgroup analysis of cases with positive lymph nodes, it appears that thoracic resection in the block may extend life expectancy (1). In another extensive database analysis (SEER), trans-thoracic and transhiatal esophagectomy were compared. In this study, transhiatal esophagectomy lost more long-term survival benefits compared to step-by-step. It seems that the mortality rate and complications after the transhiatal esophagus are lower (1, 2). Suffice it to say that the debate over the best way for esophageal cancer remains an open question. According to these studies, although this practice may violate many principles of cancer resection, including radical LN Orringer technique dissection, it plays a role such as other methods in randomized trials and an extensive database (1). Lower mediastinal lymph node (LNS) basins can be resected in an Orringer like the upper abdominal LNS, which is an attractive option for GEJ cancers. Upper mediastinal LNS above the inferior pulmonary vein, which cannot be removed with this method, rarely leads to recurrent cancer recurrence (2).
Though this technique is primarily used for lower esophageal cancer and fragile patients, we would like to present our experience in lower, upper, and middle 3rd cancer of the esophagus globally. In the United States, 16,940 esophageal cancer cases are diagnosed each year, and 15,690 deaths are expected from the disease (3). Esophageal cancer is the 7th most commonly occurring cancer in men and the 13th most commonly occurring cancer in women. There were over 500,000 new cases in 2018 (4). Incidence rates vary internationally by nearly 16-fold, with the highest rates found in Southern and Eastern Africa and Eastern Asia and the lowest rates in Western and Middle Africa and Central China, 90% of cases are squamous cell carcinoma (5-9). It is the 7th most common cancer in Iran (8) and the 3rd cause of mortality due to cancer. It is estimated that out of 35,000 deaths caused by cancer in Iran, 5,800 are due to esophageal cancer, and statistically, Iran is the 2nd country with the highest number of cancer deaths in the eastern part of the Middle East (8).
2. Objectives
The present study presents experience with open transhiatal esophagogastrectomy (Orringer) technique outcomes.
3. Methods
Medical record of patients with esophageal carcinoma, who were operated with open transhiatal technique for 25 years from 1990 to 2015 at Shohadaye Tajrish Medical Center affiliated with Shahid Beheshti University of Medical Science, was subject to study. The records had complete documentation and were followed up. Also, incomplete records were excluded.
4. Results
Overall, 114 patients were eligible. The mean age was 55 years (40 - 70); 60% were male and 40% were female. Most were from the northern provinces of Iran. All had grade 3 dysphagia and more. In the upper 3rd, there was 1 case. In the middle 3rd, 61 cases, and 52 cases had a lesion in the lower 3rd; 60% were squamous cell carcinoma, and 40% were adenocarcinoma. After resection, more than 98% of patients were in the T3 N1 - N3 stage. There were 4 mortalities: 2 were due to descending aorta tearing, 1 was due to tracheobronchial tearing, and 1 was pneumonia (Table 1). There were many complications, fortunately, transient and almost manageable by non-operative treatment (Table 2). From 40 cases of pleural effusion, only 5 cases (12.5%) needed a thoracotomy tube. Only 2 patients needed intervention from 30 patients with dysphagia; 1 case was relieved by balloon dilatation and the other needed a free jejunal flap. The anastomotic leak occurred in 5 patients and was managed expectantly. Accordingly, a recurrent laryngeal injury occurred in 1 patient. The voice got better 6 months later. Azygous vein tearing occurred in 1 patient, whose lesion was at the middle 3rd of the esophagus and adherent to it. It was managed by thoracotomy and ligation of the vein. Chylothorax was managed after a course of supportive therapy by thoracotomy and ligation of the thoracic duct. Consequently, 2-year and 5-year survival in the neoadjuvant series (50 patients) were 40% and 30%, respectively. Besides, in the adjuvant or surgery-only groups, it declined to 30% and 20% (Table 2). Two cases survived more than 15 years and their tumor size was about 2 cm. Their pathology was well-differentiated squamous carcinoma, and 6 lymph nodes were removed in these cases, which were not involved by tumor cells.
Table 1.Mortality in 114 Cases with Transhitale Esophagectomy in Shohada-Tajrish Medical Center
| Mortality | Aort Tearing | Bronchial Tearing | Pneumonia | Total |
|---|---|---|---|---|
| Number | 2 | 1 | 1 | 4 |
Table 2.Complications in 114 Cases with Transhiatal Esophagectomy in Shohada-Tajrish Medical Center from 1990 to 2015
| No. | Complication | No. (%) |
|---|---|---|
| 1 | Pleural effusion | 40 (35) |
| 2 | Dysphagia | 30 (26) |
| 3 | Anastomotic leak | 5 (4.3) |
| 4 | Anastomotic stricture | 2 (1.8) |
| 5 | Recurrent nerve injury | 1 (0.9) |
| 6 | Pneumonia | 1 (0.9) |
| 7 | Descending aorta tearing | 2 (1.8) |
| 8 | Left main bronchus tearing | 1 (0.9) |
| 9 | Azygus vein tearing | 1 (0.9) |
| 10 | Chylothorax | 1 (0.9) |
5. Discussion
More extensive surgery (radical or en bloc esophagectomy) has not been proven to have more survival benefits than non-radical counterparts but has been associated with more mortality and morbidity (1, 10-12). In this technique, all hilar and posterior mediastinal lymph nodes should be removed alongside the esophagus and sometimes (as in Siewert type I lesions) with resection of the proximal part of the stomach and celiac axis lymph nodes. En bloc esophagectomy can be done in the context of 2 fields (Ivor Lewis technique) or 3 fields (McKeown) esophagectomy. Transhiatal esophagectomy (Orringer technique) is done through 2 incisions, 1 at the neck and the other at the abdomen, only lower mediastinal lymph nodes can be removed (1, 11, 12). This technique was associated with low mortality and morbidity in more extensive studies but with no survival difference (1, 2, 10, 12). Mortality and morbidity in our series were lower than in its original series (3.5% vs. 4%) (11) perhaps due to technical and experimental issues. By applying healthy techniques and gaining more experience, mortality and complications could decline more.
From a survival perspective, we also had comparable results to its original report (11). Five-year survivals were 30% and 20% versus 48% and 23% in the neoadjuvant and non-neoadjuvant groups, respectively (11). To our knowledge, by considering more squamous cell carcinoma cases (60% vs. 37%) and more stage III cases (98% vs. 37%) in the studied series, this result is also comparable (11). The overall 5-year survival rates were comparable to some significant randomized trials: 35% vs. 47% (CROSS), 30% vs. 39% (Tepper) in the neoadjuvant group and 20% vs. 34% (CROSS), and 20% vs. 16% (Tepper) in surgery only group, respectively (10). Shortage of imaging facilities for better staging, and more squamous cell carcinoma cases may influence some suboptimal results. Today, complete resection has proved to be the most significant effect on 5-year survival (12). Five-year survival after RO resection is 15% to 40% independent from the stage of the disease and 0% to 5% after incomplete resection (12). This technique showed better results by considering 30% and 20% 5-year survival in the neoadjuvant and surgery-only groups.
5.1. Conclusions
More randomized trials are needed to incorporate various invasive and non-invasive techniques, chemotherapy, chemoradiotherapy, target therapy, and new remedies to affect survival significantly. Until achieving this success, transhiatal esophagectomy is a suitable option for old, smoker, and malnourished patients with several comorbidities. The present study and experiences (1, 2, 10, 11) indicated that non-radical surgery such as the Orringer technique is acceptable and compassable with radical esophagectomy.
