Parth Malaviya

Background:  There has been a debate around the balance of oncological and perioperative morbidity of transthoracic versus trans-hiatal surgical approaches for removing the esophagus. The American Society of Clinical Oncology (ASCO) guidelines indicate that while transthoracic esophagectomy is associated with more favorable oncological outcomes, it does not necessarily result in better quality of life compared to the trans-hiatal approach¹.

Methods:  A comprehensive literature search was conducted across the PubMed and Texas A&M Medical Sciences Library databases to compare transthoracic and trans-hiatal esophagectomy techniques. Search terms included “esophagectomy,” “transthoracic,” “transhiatal,”, “esophageal cancer, “Ivor-Lewis”, “Orringer Anastomoses”, and “McKeown.” Studies published in English from 2017 to 2024 were included. Peer-reviewed articles comparing surgical outcomes, complications, and survival rates were screened based on relevance and quality. Data extraction focused on study type, patient population, surgical approach, and key clinical outcomes. Critical appraisal was performed using CASP guidelines.

Results:  Lowchowski et al. found no significant difference in 5-year survival rates; however, more lymph nodes were removed in TTE (p<0.05). The presence of lymph node metastases (p<0.0001) and adenocarcinoma significantly influenced survival. The extent of lymph node removal in TTE may offer oncological advantages, but the surgical approach itself did not impact overall survival². Zheng et al. (ACS NSQIP, n=10,000) found Ivor Lewis esophagectomy (ILE) favored over McKeown (MCK) due to higher lymph node yields and lower complication rates³. Surgical site infections were lowest with ILE (13.1%) compared to MCK (19%) and THE (17.3%). Van Workum et al. (n=420) showed minimally invasive ILE had lower anastomotic leaks (12.4% vs. 23.3%), pulmonary complications, and 90-day mortality than minimally invasive MCK⁴. A smaller study (n=110) also reported reduced perioperative morbidity with ILE (34.7% vs. 59.0%)⁵.

Conclusion:  Studies have shown that transthoracic esophagectomy generally results in a higher lymph node yield, which is beneficial for staging and potentially for survival, but it also comes with increased risks of respiratory complications, longer hospital stays, and higher short-term mortality^6,7. Conversely, the transhiatal approach is associated with fewer respiratory complications and shorter hospital stays but may result in higher rates of anastomotic leaks and strictures^6,7.  The choice of surgical approach often depends on the patient’s overall health, tumor location, and the surgeon’s expertise and preference. The Society of Thoracic Surgeons and the American Society for Radiation Oncology also highlight that the choice between these approaches remains controversial and is influenced by institutional practices and surgeon experience⁸.

Works Cited

1. Treatment of Locally Advanced Esophageal Carcinoma: ASCO Guideline. Shah MA, Kennedy EB, Catenacci DV, et al. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2020;38(23):2677-2694. doi:10.1200/JCO.20.00866.
2. Łochowski, M., Łochowska, B., & Kozak, J. (2017). Transthoracic versus transhiatal esophagectomy – influence on patient survival. Gastroenterology Review, 12(2), 118–121. https://doi.org/10.5114/pg.2016.64609
3. Zheng R, Tham EJH, Rios-Diaz AJ, et al. A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices. J Surg Res. 2020;256:103-111. doi:10.1016/j.jss.2020.06.008
4. Propensity Score-Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive McKeown Esophagectomy. van Workum F, Slaman AE, van Berge Henegouwen MI, et al. Annals of Surgery. 2020;271(1):128-133. doi:10.1097/SLA.0000000000002982.
5. Brown AM, Pucci MJ, Berger AC, et al. A standardized comparison of peri-operative complications after minimally invasive esophagectomy: Ivor Lewis versus McKeown. Surg Endosc. 2018;32(1):204-211. doi:10.1007/s00464-017-5660-4
6. Comparative Outcomes of Transthoracic Versus Transhiatal Esophagectomy. Takahashi C, Shridhar R, Huston J, et al. Surgery. 2021;170(1):263-270. doi:10.1016/j.surg.2021.02.036.
7. Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis. Mertens AC, Kalff MC, Eshuis WJ, et al. Annals of Surgical Oncology. 2021;28(1):175-183. doi:10.1245/s10434-020-08760-8.
8. The Society of Thoracic Surgeons/­American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction. Worrell SG, Goodman KA, Altorki NK, et al. Practical Radiation Oncology. 2024 Jan-Feb;14(1):28-46. doi:10.1016/j.prro.2023.10.001.