Outcomes after Transhiatal Esophagectomies in an Eastern-European Low-Volume Center

Abstract

Surgery alone or associated with radio-chemo-therapy (RCT) as a multimodal approach remains the main method of treatment for resectable esophageal cancer (1, 2). Right transthoracic esophagectomy (Ivor Lewis technique) and transhiatal esophagectomy (Orringer procedure) are the most widely used standard techniques; the superiority of either of these methods is still a subject of intense controversy (2, 3). There is increasing evidence that among factors which influence the postoperative results, including long-term survival, in patients who undergo complex oncological resections such as esophagectomy, the hospital-volume and surgeon-volume play an important role (4-6). Background:The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV). Aims: Our analysis, which to the authors' knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania. Study Design: Retrospective observational study. Methods: In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%). Results: The majority of cancer-group patients had T3/ N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively.Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2-36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months. Conclusion: Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite being significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers.