Esophagectomy without thoracotomy: A dangerous operation?

J THoRAc

CARDIOVASC SURG

85:72-80, 1983

Esophagectomy without thoracotomy: A dangerous operation? Transhiatal esophagectomy without thoracotomy has been performed in 143 patients: 43 with benign disease and 100 with carcinomas at various levels of the esophagus (31 cervicothoracic, five upper third, 33 middle third, and 31 distal third). Esophageal resection and reconstruction were performed in a single stage in 138 patients, and the esophageal substitute was positioned in the posterior mediastinum in the original esophageal bed in 134 patients. Stomach was used to replace the esophagus in 128 patients (93%) and colon in 10 patients. The operative mortality has been 8%, the causes of death being myocardial infarction (three), respiratory insufficiency (three), innominate artery rupture (two), sepsis from mediastinal or retroperitoneal abscess (two), and pulmonary embolus (one). No death was the direct result of the technique of esophagectomy. Complications included intraoperative pneumothorax (51%), transient hoarseness (37%), anastomotic leak (12%), chylothorax (3%), and tracheal laceration (1%). Average intraoperative blood loss for the entire group has been 1,150 ml, 1,800 ml for those requiring concomitant laryngectomy and 900 ml for those undergoing esophagectomy without laryngectomy. Of 63 patients surviving resection of intrathoracic esophageal carcinomas, 86% were discharged, able to swallow, within 3 weeks of operation. Distant lymph node metastases or local tumor invasion precluded a curative resection in 70% of our patients with carcinoma, and the overall average duration of survival has been only 12.5 months. However, of 15 surviving patients with intrathoracic esophageal carcinoma who had "curative" resections, 10 are alive and tumor free from 8 to 60 months (average 31 months) postoperatively. A thoracic incision is seldom required to resect the esophagus for either benign or malignant disease. Transhiatal esophagectomy without thoracotomy is a safe, well-tolerated operation, the "hazards" of which can be minimized by careful technique and experience.

Mark B. Orringer, M.D., and Jay S. Orringer, M.D. (by invitation), Ann Arbor, Mich.

Our

continuing efforts to reduce the morbidity and mortality rates for esophageal resection and reconstruction prompted us to advocate the technique of transhiatal esophagectomy without thoracotomy in patients with both benign and malignant disease requiring esophageal replacement.' By eliminating the need for a thoracotomy, this procedure reduces the operative physiological insult to the patient, and use of a cervical esophageal anastomosis is not associated with the disastrous results of disruption of an intrathoracic anastomosis. Our preliminary report describing transhiatal esophagectomy in 26 patients was criticized for advocating a

dangerous operation which violated the basic surgical principles of adequate exposure and hemostasis. This paper presents our cumulative clinical experience with this operation in 143 patients requiring esophagectomy. Our growing facility with this technique and the improved operative results in these patients have provided us ample justification for our current belief that transhiatal esophagectomy without thoracotomy is the preferred approach in virtually all patients requiring esophageal resection. Patients

Read at the Sixty-second Annual Meeting of The American Association for Thoracic Surgery, Phoenix, Ariz., May 3-5, 1982. Address for reprints: Mark B. Orringer, M.D., University of Michigan Medical Center, Section of Thoracic Surgery, C7079, Box 32, Ann Arbor, Mich. 48109.

During the past 5 years, transmediastinal esophagectomy without thoracotomy, as described previously,' has been performed in 143 patients, of whom 43 (30%) had benign disease necessitating esophageal replacement and 100 (70%) had carcinoma (Table I). The patients with benign disease included 12 men (28%) and 31 women (72%), ranging in age from 18 to 86 years (average 48 years); 28 (65%) had lost from 4.5 to 45 kg (average 10 kg). Seventy-seven (77%) of the patients

72

0022-5223/83/010072+09$00.90/0

From the Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Mich.

© 1983 The C. V. Mosby Co.

I

Volume 85 , Number 1

withcarcinoma were men and 23 (23%) women, ranging in age from 38 to 92 years (average 61 years); 69 (69%) had lost from 2.3 to 29.5 kg (average 10.5 kg). Sixty-six patients had squamous cell carcinoma of the esophagus. Additional tumors included a thyroid carcinoma involving the cervicothoracic esophagus, an adenosquamous carcinoma of the upper thoracic esophagus, middle-third adenocarcinoma arising in a columnar-lined (Barrett's) esophagus (five cases), and distal third adenocarcinoma (27 cases). The 31 patients with cervicothoracic esophageal carcinoma underwent laryngopharyngectomy, transhiatal esophagectomy, and either pharyngogastrostomy or pharyngocolostomy; in 20 (65%) an anterior mediastinal tracheostomy, as described previously," was required because of the need to divide the trachea behind the sternum. Neuromotor esophageal dysfunction was the commonest benign condition necessitating esophagectomy, all 20 patients with motor disorders having undergone prior esophageal operations which ultimately failed." The six patients with reflux strictures were not believed to be candidates for intraoperative dilation and Collisgastroplasty-fundoplication operations, two having chronically perforating Barrett's ulcers, two being mentally retarded and severely debilitated, and two having undergone multiple antireflux operations. All four patients with acute caustic injuries underwent emergency transhiatal esophagectorny, cervical esophagostomy, and feeding jejunostomy; in three esophageal reconstruction was performed 2 to 8 weeks later. One patient, who had undergone an antiperistaltic retrosternal bypass of the stenosed esophagus following a caustic injury, had recurrent aspiration pneumonia from reversed retrosternal colonic emptying and spasm. The retrosternal colon was resected, a transmediastinal esophagectomy performed, and a cervical esophagogastric anastomosis constructed. Mediastinal inflammation from prior esophageal operations, perforations, or radiation therapy has not been a contraindication to transhiatal esophagectomy. Thirty-six (84%) of our 43 patients with benign disease have had previous procedures, including hiatal hernia repair (18 patients), esophageal dilatation (16 patients), thoracic esophagomyotomy (10 patients), repair of esophageal atresia in infancy (three patients), radiation therapy (two patients), repair of perforation (two patients), and varying reconstructive procedures (six patients). In all but five patients, esophageal resection and reconstruction were performed at the same operation (Table II). The stomach was used as the visceral esophageal substitute in 128 (93%) of our patients who

73

Esophagectomy without thoracotomy

January, 1983

Table I. Indications for transhiatal esophagectomy (143 patients) No.

Benign conditions Neuromotor dysfunction With gastroesophageal reflux Spasm Achalasia Scleroderma Esophageal atresia Without gastroesophageal reflux Spasm Achalasia Chronic stricture Distal third Barrett's ulcer-chronic perforation Peptic stricture in mentally retarded Recurrent peptic stricture Following instrumental perforation Caustic ingestion Idiopathic upper third stricture Radiation Postemetic stricture Monilial Following laryngopharyngectomy reconstruction Acute injury Caustic ingestion Perforation proximal to reflux stricture Malfunctioning substernal colon

20 12

4 3 3 2 8 6 2 17

7 2 2 2 I 4 2 I I I

I 5 4' I I

Total

43

Esophageal carcinoma Cervicothoracic Upper third thoracic Middle third thoracic Lower third thoracic

31 5 33 31

Total

100

underwent immediate esophageal replacement. Partial or total gastric resections were required in four of eight patients with caustic injuries. Colon was used to replace the esophagus in three patients with caustic injuries and in patients with carcinoma only when prior gastric resection for peptic ulcer disease made the stomach an unsuitable esophageal substitute. The visceral esophageal substitute was positioned within the posterior mediastinum in the original esophageal bed in all but four patients, in whom either residual posterior mediastinal tumor or fibrosis and narrowing prevented adequate positioning of the stomach for a tension-free cervical anastomosis. In these latter four patients, the retrostemal route was used. In every patient with a normal-sized stomach, the gastric fundus readily reached to the neck for a tension-free cervical anastomosis. Total gross tumor removal without microscopic evi-

The Journal of

74 Orringer and Orringer

Thoracic and Cardiovascular Surgery

Table ll. Esophageal reconstruction after transhiatal esophagectomy Benign (No.)

Reconstruction Cervical esophagogastrostomy Posterior mediastinal route Retrostemal Pharyngogastrostomy Cervical esophagocolostomy Pharyngocolostomy Delayed 2-8 Weeks None (cervical esophagostomy, jejunostomy)

32 31 I

Table llI. "Curative" operations in patients undergoing transhiatal esophagectomy for carcinoma Type of resection Palliative With nodal involvement t Tumor site

No.

No.

%

No.

Intrathoracic Upper third Mid third Distal third

5 33 31

I 9 7

20 27 23

2 9 19

Subtotal

69

17

25

Cervicothoracic

31

13

42

100

30

30

Total

I

With local invasion:j:

I

%

No.

40 27 61

3 15 6

30

43

24

38

8

29

12

39

38

38

36

36

%

60 45 19

*Total gross tumor removal without microscopic vascular or lymphatic invasion. t"Distant" lymph node metastases (e.g .• celiac axis or cervical lymph node involvement by intrathoracic carcinomas or mid-mediastinal nodal metastases from cervicothoracic carcinomas). :j:Gross adherence to prevertebral fascia or tracheobronchial tree, or microscopic vascular or lymphatic invasion.

dence of vascular or lymphatic tumor invasion justified a designation of "curative" resection in only 25% of patients with intrathoracic esophageal carcinomas and in the 42% of patients with cervicothoracic esophageal malignant tumors; thus the overall' 'curative" resection rate was 30% (Table Ill). Postoperative radiation or chemotherapy or both were generally used in patients who had palliative resections. Results Complications. There were no intraoperative deaths. One patient with scleroderma, an esophageal stricture, and severe nutritional cirrhosis lost 6,000 rnl

98 94 4

28 3 3

30 7 3 3 2

100

143

3 2 43

Total

66 63 3

2 4

Totals

Curative *

Carcinoma (No.)

of blood during the operation following a retractor injury of the soft, enlarged liver. Measured intraoperative blood loss among the remaining 142 patients averaged 1,150 ml, 1,800 ml for those requiring concomitant laryngectomy and 900 ml for those undergoing esophagectomy without laryngectomy. A splenectomy was required because of intraoperative injury in 15 patients (l 0%). Pneumothorax, recognized and treated intraoperatively with a chest tube, occurred in 73 patients (51 %). Left recurrent laryngeal nerve paresis has occurred in 37% of patients undergoing a cervical anastomosis and has resolved spontaneously within 2 to 12 weeks of operation in all but three patients; these three required a Teflon injection of the vocal cord. Postoperative chyle fistulas occurred in six patients. Two of the fistulas were cervical and followed laryngopharyngectomy; both were controlled with wound catheter suction and a low-residue elemental diet via the jejunostomy tube. A thoracotomy was performed in the four patients who had a chylothorax, and the injured thoracic duct was ligated successfully. Iatrogenic hypoparathyroidism (in eight of 31 laryngopharyngectomies) and postoperative innominate artery rupture (in two of 20 anterior mediastinal tracheostomies) have occurred only in our patients undergoing radical cervicothoracic esophageal resections. There were two intraoperative tracheal lacerations. One involved the high membranous trachea and was exposed and repaired through a partial upper sternal split. The other tear involved the membranous carina and was managed by guiding the endotracheal tube into the left main-stem bronchus, ventilating one lung, and performing a substernal gastric bypass. Then, through a right thoracotomy, the esophagectomy was completed and the tracheal tear repaired. The patient had an uneventful postoperative course. The relationship between the type of anastomosis and the frequency of anastomotic leaks is shown in Table IV. Pharyngeal anastomotic leaks following

Volume 85 Number 1 January, 1983

Esophagectomy without thoracotomy

75

Table IV. Anastomotic leaks after transhiatal esophagectomy (138 anastomoses) Frequency of leaks Benign

Carcinoma Type of reconstruction

No.

Cervical esophagogastrostomy Posterior mediastinal route Retrostemal route Pharyngogastrostomy Cervical esophagocolic Pharyngocolic

5/66 3/63 2/3 8/28 0/3 1/3 14/100

Totals

I

%

No.

8 5 67

3/32 2/31 III

29 0 33 14

laryngopharyngectomy occurred in 29%, but like cervical leaks, tended to be well controlled with local drainage. Five percent of patients who had a cervical esophagogastric anastomosis after the stomach was positioned in the posterior mediastinum had anastomotic disruptions, whereas three of four patients with retrosternal gastric interpositions had anastomotic leaks. Mortality. There were 11 deaths within 30 days of operation for an overall operative mortality of 8%, five after esophagectomy for carcinoma and three in patients being treated for benign conditions. Causes of death included respiratory insufficiency (three), acute myocardial infarction (three), innominate artery rupture (two), sepsis from mediastinal or retroperitoneal abscess (two), and pulmonary embolus (one). Two patients died of respiratory insufficiency following massive aspiration of retained intrathoracic gastric contents during the first postoperative week. The two patients who died of sepsis had carcinoma of the middle third of the esophagus. In one, an extensive tumor was fractured away from the prevertebral fascia. Because of the residual posterior mediastinal tumor, the stomach was positioned retrostemally. The patient died after experiencing an anastomotic leak followed by progressive respiratory insufficiency and sepsis. At postmortem examination, there was a large posterior mediastinal abscess. The other patient had liver metastases at operation; after palliative esophagectomy, deep thrombophlebitis of the leg and progressive ascites developed, and the patient ultimately died of sepsis. A large retroperitoneal abscess was found at autopsy. Six additional patients did not leave the hospital alive following esophagectomy. They died from 6 weeks to 4 months later of fulminant carcinomatosis following resection of cervicothoracic carcinoma (two), hepatorenal syndrome (one), cerebrovascular accident (one),

Total

I

I

No.

%

9

0/2 0/4

0 0

3138

8

8

8/98 5194 3/4 8/30 0/7 1/3

6 100

%

5 75

27 0 33 12

17/138

Table V. Days of hospitalization following transhiatal esophagectomy (123 patients undergoing one-stage resection and reconstruction and leaving hospital alive) Hospitalization after operation 7-14 days No. Carcinoma Upper third Middle third Lower third Cervicothoracic Benign conditions Totals

5 28 30 23 37 123

15-21 days

No.

I%

No.

3 18 25 6 23 75

60 64 83 26 62 61

5 3 5 6 19

1% 18 10

22 16 15

Average . (days)

17 18 13 24 16 17

respiratory insufficiency (one), and renal failure (one). Thus the "hospital" mortality among all 143 patients was 12% (17 patients). Follow-up. The duration of hospitalization following transhiatal esophagectomy and immediate reconstruction is shown in Table V. The longest hospitalizations followed resection of cervicothoracic esophageal carcinoma, which often necessitated concomitant mediastinal tracheostomy. Of 63 patients surviving resection of intrathoracic esophageal carcinomas, 86% (54) were discharged, able to swallow, within 3 weeks of operation and 73% (46) within 7 to 14 days. Of 37 patients surviving resection and reconstruction for benign conditions, 78% (29) were discharged within 3 weeks and 62% (23) within 7 to 14 days. Complete follow-up is available for all patients. Of the 86 patients with carcinoma who survived operation and left the hospital alive, 51 (59%) have died from 6 weeks to 38 months (average 9.3 months) after opera-

The Journal of Thoracic and Cardiovascular Surgery

7 6 Orringer and Orringer

Table VI. Survival after transhiatal esophagectomy for carcinoma Survival

Tumor site Intrathoracic Upper third Middle third Distal third Subtotal Cervicothoracic Total

No. surviving operation

Average survival (mo)

5 28 30 63

9.2 9.8 16.3 12.9

23 86

10.7 12.5

12 moormore No.

I

18moormore

%

No.

9 9 13 22

32 32 42 35

7

30 34

29

tion, and all but five of these died of carcinomatosis. Two patients have died of aortogastric fistula formation within 3 months of operation. The remaining 35 patients have been followed up from 1 to 60 months (average 16.5 months). Twelve are alive with metastatic disease from I to 32 months (average 10 months) after operation. Twenty-three patients (27%) are alive and tumor free from 1 to 60 months (average 20 months) after esophagectomy. Among the 63 surviving patients with carcinoma of the intrathoracic esophagus, 35% have lived 12 months; 17%, 24 months; and only 10%, 36 months or more (Table VI). The longest survival has been in patients with distal third tumors, 42% of whom survived 12 months and 29%, 24 months or more. Of 15 surviving patients with intrathoracic esophageal carcinoma who were believed to have a "curative" resection, three have died of carcinomatosis 6 weeks, 18 months, and 38 months after operation and two are alive but with metastases after 5 months and 34 months. The remaining patients are alive and tumor free after 8,9, 10, 18, 21,38,47,48,52, and 60 months, respectively. The latter five had distal third adenocarcinomas. Of the 40 patients with benign disease who survived esophagectomy and visceral esophageal substitution, six have died from I to 41 months (average 14 months) after operation. The causes of death in these patients have been carcinoma (two), myocardial infarction (one), and suicide (three); in the last three patients, the esophagectomies were originally performed for caustic injuries sustained in their first suicide attempts. The remaining 34 patients have been followed up for 1 to 50 months (average 20 months).

Functional results of visceral esophageal substitution. Benign conditions. Among the 34 living patients and three who have died after a minimum follow-up of 12

I

24 mo or more

%

No.

3 3

II II

10

13

32 21

2 2 9 II

5

22

4

18

21

15

I

36 mo or more

%

No.

7 7 29 17

I I

17 17

I

%

6

4 4 16 10

I

4

7

8

5

months, 32 (86%) have been able to eat regular, unrestricted diets and are regarded as having a "good" result of visceral esophageal substitution. Five (14%) have had a "poor" result, i.e., frequent abdominal and chest pain, cramping after eating, and early satiety that prevents a normal meal. Four of these latter patients underwent esophagectomy for recurrent esophageal spasm and, in each case, years of chronic abdominal and chest pain, as well as psychiatric therapy, antedated the esophageal resection. The fifth patient underwent a colonic interposition following multiple unsuccessful antireflux operations. All patients undergoing a cervical esophageal anastomosis are instructed to return for outpatient anastomotic dilatation if any degree of cervical dysphagia occurs after discharge. Thus 24 of 37 patients (65%) with benign disease have had such outpatient dilatations for cervical dysphagia, generally between one and three times during the first 6 postoperative months. Of these, however, only five (14%) have true anastomotic strictures which have necessitated regular bougienage. In three of these latter patients, the stomach was anastomosed either to scarred pharynx or cervical esophagus following either caustic injury (two) or radiation therapy (one). In one patient an anastomotic stricture developed after healing of a leak; the anastomosis was revised at 18 months and dilatation has not been required for 6 months. Thirteen patients (35%) have admitted experiencing some regurgitation after operation, generally when bending forward after meals. Only four give a history of nocturnal regurgitation, two following cervical esophagogastrostomy and two after cervical esophagocolostomy. No patient has had any pulmonary complications ofreflux. Fourteen patients (38%) have experienced transient postvagotomy diarrhea, generally well controlled with diet and medication (diphenoxylate).

Volume85 Number 1 January. 1983

Two patients have required pyloroplasty because of the late development of gastric outlet obstruction after pyloromyotomy. Carcinoma. Among the 63 surviving patients with carcinoma of the intrathoracic esophagus, 61 (97%) have been able to swallow a regular diet until the time of their death and represent a "good" result of visceral esophageal substitution. Twenty-six (41%) have had outpatient dilatations for postoperative cervical dysphagia, but only three had true anastomotic strictures necessitating regular bougienage. Twelve patients (21 %) have experienced postoperative regurgitation, but none has had any pulmonary complications of reflux. Twenty-six (41%) have had transient postvagotomy diarrhea. All 23 patients with cervicothoracic carcinomas could eat regular diets after operation. Two patients have pharyngogastric anastomotic strictures that are dilated regularly, and five have had postvagotomy diarrhea. Regurgitation is far more common after esophagectomy when the upper esophageal sphincter is resected, and this has been experienced by 17 (74%) of our patients surviving laryngopharyngectomy.

Discussion Transhiatal esophagectomy has been applicable in virtually every patient requiring an esophageal resection, including those with a megaesophagus of achalasia and those who have had a previous thoracic esophagomyotomy. With more difficult dissections, direct exposure of the esophagus is facilitated by small retractors in the diaphragmatic hiatus. Many patients with esophageal carcinoma metastatic to abdominal or cervical lymph nodes are found to have a primary tumor that is still grossly confined to the esophagus, mobile within the mediastinum, and resectable through the transhiatal route. In such patients, esophagectomy and a cervical esophagogastrostomy provide efficient, safe palliation with essentially the morbidity of a laparotomy; 86% of our patients with esophageal carcinoma who survived operation left the hospital, able to swallow, within 3 weeks. With most of our intrathoracic esophageal carcinomas, transhiatal resection has been possible, aortic or tracheobronchial involvement forcing us to perform a substernal gastric bypass of the excluded esophagus in only five of our last consecutive 105 patients. Although fracturing a tumor away from the prevertebral fascia may offend those advocates of a direct "cancer operation," we do not believe that the 1 or 2 mm "margin" obtained by cutting an esophageal tumor away from the spine during a transthoracic esophagectomy provides any better chance for cure

Esophagectomy without thoracotomy

77

than a "blunt" resection. In only one of our patients has posterior mediastinal tumor growth resulted in subsequent dysphagia from compression of the intrathoracic stomach. The majority died of advanced, widespread disease long before the large-capacity stomach could be so compressed by local tumor progression that obstruction occurred. Further, that 10 of 15 patients to survive "curative" resections for carcinoma of the intrathoracic esophagus are alive and tumor free at 8, 9, 10, 18, 21, 38, 47, 48, 52, and 60 months, respectively, indicates that transhiatal esophagectomy does not preclude long-term survival and potential cure. Transhiatal esophagectomy, with the stomach positioned in the posterior mediastinum, avoids a number of problems associated with substernal gastric bypass of the excluded thoracic esophagus." Resection of the medial clavicle and adjacent manubrium to prevent encroachment of the stomach at the anterior thoracic inlet is not required. Anastomotic disruption is less frequent when the stomach is positioned in the posterior mediastinum. Postoperative anastomotic dilatation, if required, is technically easier when one does not have to negotiate the anterior angulation formed by.the junction of the cervical esophagus and the retrosternal stomach. Finally, the potential morbidity of an excluded esophagus is avoided. For these reasons, malignant tracheoesophageal fistula has become virtually our only indication for substernal gastric bypass of the excluded thoracic esophagus. From a functional standpoint, the stomach brought through the posterior mediastinum and anastomosed to the cervical esophagus is proving to be a better esophageal substitute, attendant with fewer long-term complications, than colon." The 37% incidence of vocal cord paresis in our patients undergoing a cervical anastomosis is unacceptable and is currently being reduced by avoiding the placement of any retractors against the tracheoesophageal groove during the operation. We believe that this traction injury to the recurrent laryngeal nerve has been responsible, in part, for transient cricopharyngeal muscle dysfunction and secondary cervical dysphagia necessitating bougienage in 50% of our patients. Nevertheless, this problem has been relatively minor and readily managed by outpatient Hurst-Maloney bougienage. The improved ability to swallow after operation far outweighs the minor annoyance of an occasional dilation. Transhiatal esophagectomy is associated with far less physiological insult to the patient than the more traditional combined transthoracic and abdominal approaches. We remain firm in our conviction that a

The Journal of

7 8 Orringer and Orringer

sound knowledge of thoracic anatomy and surgical complications and their management is vital in performing esophagectomy and esophageal reconstruction. However, a thoracotomy is unnecessary in the majority of patients requiring esophagectomy, and its avoidance is rewarded by fewer postoperative complications and more rapid mobilization of the patient. Implicit in any discussion of transhiatal esophagectomy is a warning not to persist with the dissection if there is excessive fixation of the intrathoracic esophagus to adjacent tissues. Injuries to the membranous trachea or the aorta will inevitably occur if, in one's enthusiasm to remove the esophagus "blindly," one performs an overly aggressive, careless dissection. Transhiatal esophagectomy without thoracotomy is a safe, welltolerated operation, the "hazards" of which can be minimized by careful technique and experience. REFERENCES Orringer MB, Sloan H: Esophagectomy without thoracotomy. J THORAC CARDIOVASC SURG 76:643-654, 1978 2 Orringer MB, Sloan H: Anterior mediastinal tracheostomy. Indications, techniques, and clinical experience. J THoRAc CARDIOVASC SURG 78:850-859, 1979 3 Orringer MB, Orringer JS: Esophagectomy. Definitive treatment for esophageal neuromotor dysfunction. Ann Thorac Surg 34:237-248, 1982 4 Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J THoRAc CARDIOVASC SURG 70:836-851, 1975

Discussion DR. ROBERT D. HENDERSON Toronto. Ontario. Canada

Dr. Orringer has brought to the fore a very provocative issue. I do not believe the answers are yet available as to the best approach to the management of esophageal malignant disease. Nevertheless, I am greatly concerned that his type of surgical approach will leave behind lymph nodal tissue and similar adjacent tissue that could be treated by a more radical surgical procedure. Before this operation is accepted as a routine method of resection of the esophagus, the long-term results should be compared with the long-term results achieved by surgeons such as Dr. Skinner, who are using a more radical approach. We should analyze our data carefully before regarding all esophageal operations as palliative. DR. AGUSTIN ARBULU Detroit, Mich.

At Wayne State University in Detroit, following the leadership of Dr. Zwi Steiger and my associate, Dr. Ingida Asfaw, in a series that is now approaching a hundred cases of carcinoma of the esophagus, this technique has been used in

Thoracic and Cardiovascular Surgery

about one third of the patients. The technique is quite safe and eliminates the respiratory problems that many of these patients have. As presented at the meeting of this Association in Washington last year, at Wayne State we are using a combined protocol of chemotherapy, radiotherapy, and surgical therapy. The chemicals that are used in these patients prior to the operation are quite damaging to the lungs. It is remarkable to see the elimination of ventilatory complications in these patients with the technique that Dr. Orringer has described. I have one question. I noticed that his patients lost about 1,100 ml of blood following the procedure. We had one episode of bleeding that necessitated a conversion to a thoracotomy in one of our patients, but the patient did well afterward. Did any of Dr. Orringer's patients require conversion to a thoracotomy? DR. 0 R R I N G E R (Closing) I would like to thank Dr. Henderson and Dr. Arbulu for their comments. I agree completely with Dr. Henderson that the final answer is not yet in and that we need to see long-term survival rates before we can comment on the efficacy of this operation in controlling carcinoma. It is true, as Dr. Henderson said, that transhiatal esophagectomy may leave behind lymph nodes that are involved with carcinoma. However, one must ask whether removal of a tumor that has already spread to the lymphatics provides any more meaningful increased longevity. Dr. Arbulu has expressed concern about blood loss with the transhiatal esophagectomy. Inevitably, with any operation, there are occasional hemorrhagic complications. Our average measured intraoperative blood loss in patients undergoing esophagectomy without laryngectomy, however, has been 900 ml, and we have not had to explore any patient's chest for postoperative bleeding. In closing, regarding the matter of using this technique in patients with carcinoma of the esophagus, I believe that the idea of curing cancer by more and more radical resections is passe. The concept of cytoreduction or "debulking" the tumor, then utilizing combined radiation and chemotherapy, is the current hope for patients with esophageal carcinoma and potentially will provide the most meaningful long-term survival.

Manuscript reviewer's comment In this paper, Dr. Orringer presents his experience with 143 blunt esophagectomies as evidence for the safety of this operation. He concludes: "A thoracic incision is seldom required to resect the esophagus for either benign or malignant disease." Dr. Orringer's data disprove his conclusion. For example, there were 20 hospital deaths (11 within 30 days) among the 143 patients, and six of 43 (13%) patients with benign disease died! This is an unacceptable mortality for operations for benign disease. It is especially so since 20 of the 43 patients were operated upon for neuromotor disorders which might well have been managed by less radical proce-

Volume 85 Number 1 January, 1983

dures. At least four of the operative deaths were caused by technical complications. For carcinoma, this approach completely abandons any pretext of trying to cure the patient, which is surely part of a surgeon's responsibility whenever possible. The 2 year survival rate in Dr. Orringer's series is reported as 15% (15/ 100) among patients undergoing esophagectomy for cancer, whereas the 5 year survival rate is better than this in many reported series of standard or radical esophagectomy. The anastomotic leakage rate of 14% (17/138) is more than twice the generally accepted level. At least 50 patients required postoperative outpatient dilatations, of whom at least eight had a persistent stricture. The number of intraoperative complications from technical causes is high, including two tracheal tears, six instances of chylothorax, a 37% incidence of vocal cord palsy, and a 50% incidence of pneumothorax even though a thoracotomy was not performed. These data clearly support the conclusion that this is a dangerous operation as compared to other forms of esophagectomy. The author's introductory argument that thoracotomy is a more dangerous operation than a major laparotomy has been discredited many times. Dr. Orringer does not acknowledge the long history and previous abandonment of this type of esophagectomywithout thoracotomy dating back to the era of George Gray Turner in the 1930s. I am afraid that Dr. Orringer is way out on a limb with this advocacy of this operation. This paper presents his extensive data in an honest way andcan be reconstructed to define a proper limited role for the operation. However, the conclusions and recommendations made by Dr. Orringer are not supported by this experience. In my practice, the role of esophagectomy without thoracotomy is limited to the removal of a normal residual esophagus following a radical operation for extirpation of carcinoma of the cervical esophagus. When the indications are limitedin this way, the operation can be performed with little morbidity and accomplish the removal of an otherwise blind segmentof potentially neoplastic esophageal epithelium. This is the only circumstance in which I believe the operation described by Dr. Orringer is currently warranted. David B. Skinner, M.D. Chicago, Ill.

Response There is nothing healthier for the progress of surgery than honest, intellectual disagreement among proponents of differingoperative approaches, and it is refreshing to witness some of the controversy that has been engendered by our "rediscovery" of an old operation-transhiatal or blunt esophagectomy. Unfortunately, in his enthusiasm to "shoot down" the technique of esophagectomy without thoracotomy, Dr. Skinner has misquoted and misinterpreted our data. Among our 143 patients, 100 with carcinoma and 43 with benign disease undergoing esophagectomy without thoracotomy, there were 11 (8%) operative deaths, i.e., deaths within 30 days of operation, none intraoperatively. Three (7%), not six, of 43 patients with benign disease died. Six additional patientsdid not leave the hospital alive, for an overall hospital

Esophagectomy without thoracotomy

79

mortality of 12% (17/143 patients). Among these latter six patients, five underwent concomitant laryngopharyngectomies for cervicothoracic tumors and one had resection of a mid-third carcinoma. The hospital mortality rates for each subgroup of our patients, then, are as follows: benign disease 7% (3/43), intrathoracic esophageal carcinoma 9% (6/69), and cervicothoracic esophageal carcinoma 26% (8/31), for an overall mortality of 12% (17/143). The high hospital mortality following one-stage laryngopharyngectomy and esophageal reconstruction, usually with an anterior mediastinal tracheostomy, is a reflection of the magnitude of this undertaking, particularly in patients who have undergone prior head and neck radiation. Our mortality figures in the remaining patients are well within accepted limits. In fact, they are lower than those of many reported series of standard transthoracic esophagectomies. The only two instances, not four, of "operative" technical deaths we could possibly identify are two patients who developed mediastinal or retroperitoneal abscesses following the fracturing of large mid-thoracic tumors away from the prevertebral fascia. Our reported 2 and 3 year survival rates of 17% and 8%, respectively, may be lower than the 5 year survival rate reported in some, but not many, series of standard or radical esophagectomies in non-Oriental patients. A look at our data regarding anastomotic leaks, presented in Table I V, will show that our overall rate of anastomotic leak was .12%, not 14% (17/138 patients). If the 30 pharyngeal anastomoses after laryngopharyngectomy are excluded from consideration (and this is not unreasonable, since these require the maximum cephalad reach of stomach and often involve suturing to previously irradiated tissues), there were eight leaks (8%) in 98 cervical esophagogastric anastomoses, five (5%) in 94 patients undergoing placement of the stomach in the posterior mediastinum in the original esophageal bed. These figures, again, are well within accepted limits. We have utilized liberally outpatient Hurst-Maloney bougienage in any patient who, after a cervical esophagogastric anastomosis, had any degree of dysphagia in follow-up. Thus, although 50 of our patients have had dilatation postoperatively, eight patients (8%) have developed a true persistent stricture. Dr. Skinner is correct in stating that the absolute number of our intraoperative complications from technical causes is high. However, the relative significance of these complications must be analyzed. The intimate relationship between the mediastinal pleura and esophagus is known to every esophageal surgeon, and it is hardly surprising that one or both pleural cavities are entered during transhiatal esophagectomy. This "complication" is readily detected and treated with a chest tube and is a small price to pay for avoidance of a major thoracotomy. We have reported six chyle fistulas, including four, not six, chylothoraces and two cervical chyle leaks (after laryngopharyngectomy). All of us have seen chylothoraces following transthoracic operations. Therefore, I am not dismayed by our 3% (4/143) incidence of this relatively easily managed complication after transhiatal esophagectomy. Our most significant technical complications have been tra-

The Journal of

80

Orringer and Orringer

cheal tears in 1% (2/143 patients) and transient vocal cord paresis. not paralysis, in 37%. I initially felt that the recurrent laryngeal nerve injury was unavoidably occurring intrathoracically during blunt dissection of the esophagus away from the aortic arch. In construction of our last 18 consecutive cervical esophageal anastomoses, however, we have assiduously avoided placement of any retractor against the tracheoesophagel groove, and we have not had a single episode of postoperative hoarseness or vocal cord palsy. In my opinion, in contrast to Dr. Skinner's, these data clearly support our conclusion that esophagectomy without thoracotomy is not a dangerous operation when compared to other forms of esophagectomy. The abdominal incision that I use routinely is supraumbilical, extending from the xiphoid to the umbilicus. That the physiological insult of this limited upper abdominal incision is less than that of the combined thoracic and abdominal incisions used for standard transthoracic esophagectomy and esophageal reconstruction is simply irrefutable. I have performed transhiatal esophagectomy successfully in elderly debilitated patients for whom I frankly would not even have considered a thoracotomy; 19 of our patients have been between 70 and 79 years of age and five, between 80 and 92 years.

Thoracic and Cardiovascular Surgery

The era of radical operations intended to "cure" cancer is coming to an end. Radical mastectomy has given way to "lumpectomy." Pancreaticoduodenectomy is now seldom advocated for pancreatic carcinoma. Radical esophagectomy for esophageal carcinoma has shown little consistent ability to increase survival. Cytoreduction, or debulking of tumors, in combination with chemotherapy or immunotherapy, offers the most promising future hope for long-term survival after operations for cancer. As recent reports of series of esophagectomy without thoracotomy have begun to appear in the surgical literature from our country and abroad, it is apparent that the "limb" Dr. Skinner feels I am out on is being supported by an increasing number of surgeons. After having performed more than 150 transhiatal esophagectomies for virtually every imaginable type of esophageal disease, I find it difficult to conclude anything other than the fact that a thoracotomy is seldom required to resect the esophagus. Nothing stifles progress like the yoke of tradition. Those who criticize the technique of esophagectomy without thoracotomy for diseases of the intrathoracic esophagus might do well to try it-they might like it! Mark B. Orringer, M.D. Ann Arbor. Mich.