TY - JOUR
T1 - Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus
AU - Hulscher, Jan B.F.
AU - van Sandick, Johanna W.
AU - de Boer, Angela G. E. M.
AU - Wijnhoven, Bas P. L.
AU - Tijssen, Jan
AU - Fockens, Paul
AU - Stalmeier, Peep F M
AU - ten Kate, Fiebo J. W.
AU - van Dekken, Herman
AU - Obertop, Huug
AU - Tilanus, Hugo W.
AU - Van Lanschot, J. Jan B.
N1 - Copyright 2002 Massachusetts Medical Society
PY - 2002/11/21
Y1 - 2002/11/21
N2 - BACKGROUND: Controversy exists about the best surgical treatment for esophageal carcinoma.METHODS: We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined.RESULTS: A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died--74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent).CONCLUSIONS: Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.
AB - BACKGROUND: Controversy exists about the best surgical treatment for esophageal carcinoma.METHODS: We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined.RESULTS: A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died--74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent).CONCLUSIONS: Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.
KW - Adenocarcinoma/mortality
KW - Adult
KW - Aged
KW - Cost-Benefit Analysis
KW - Disease-Free Survival
KW - Esophageal Neoplasms/mortality
KW - Esophagectomy/economics
KW - Female
KW - Follow-Up Studies
KW - Health Care Costs
KW - Humans
KW - Male
KW - Middle Aged
KW - Neoplasm Recurrence, Local/epidemiology
KW - Quality-Adjusted Life Years
KW - Survival Analysis
U2 - 10.1056/NEJMoa022343
DO - 10.1056/NEJMoa022343
M3 - Article
C2 - 12444180
SN - 0028-4793
VL - 347
SP - 1662
EP - 1669
JO - New England Journal of Medicine
JF - New England Journal of Medicine
IS - 21
ER -