Transhiatal Esophagectomy Without Thoracotomy for
Carcinoma of the Thoracic Esophagus
MARK B. ORRINGER, M.D.
Transhiatal esophagectomy (THE) without thoracotomy was
performed in 100 patients with carcinoma of the thoracic esoph-
agus (7 upper, 45 mid, and 48 lower third). The esophagus was
replaced with stomach (96) or colon (4). Intraoperative com-
plications included pneumothorax requiring a chest tube(s) (63)
and membranous tracheal tear (2). Blood loss averaged 880 ml.
Postoperative complications included transient recurrent laryn-
geal nerve paresis (31), anastomotic leak (5), and chylothorax
(2). There were no intraoperative deaths or re-explorations for
postoperative bleeding. Six hospital deaths resulted from as-
piration pneumonia (2), retroperit6neal or mediastinal abscess
(2), pulmonary embolus (1), and respiratory insufficiency (1).
Postoperative hospitalization averaged 14 days. Actuarial sur-
vival among the 94 operative survivors is 82% at 6 months, 52%
at 12 months, 32% at 24 months, 22% at 36 months, and 17%
at 48 months. Of the operative survivors, 15% have lived 2 years
or more and 10% are clinically disease free. THE is safe, as-
sociated with a low morbidity, and achieves excellent palliation
and survival at least as good as that reported in many series of
transthoracic esophagectomies for esophageal carcinoma.
IN PATIENTS REQUIRING esophagectomy and visceral
esophageal substitution, the physiologic insult of com-
bined thoracic and abdominal incisions and the disastrous
results of disruption of an intrathoracic esophagogastric
anastomosis remain the leading causes of operative mor-
bidity and mortality. Both of these problems are circum-
vented by the technique of transhiatal esophagectomy
(THE), which both avoids a thoracotomy and utilizes a
cervical esophageal anastomosis. Since our preliminary
report advocating THE,' we have used this operation in
190 patients requiring esophagectomy, 133 for carcinoma
and 57 for benign esophageal disease. Our growing facility
with this technique, as well as the reduced perioperative
morbidity in these patients, have served as justification
for our current view that THE is the preferred approach
in most patients requiring esophageal resection.2 Con-
troversy continues to surround the relative safety of this
operation, particularly in patients with carcinoma, and
Presented at the 104th Annual Meeting of the American Surgical
Association, Toronto, Canada, April 25-27, 1984.
Reprint requests: Mark B. Orringer, M.D., Professor of Surgery, The
University of Michigan Hospitals, Section of Thoracic Surgery, C7079,
Box 32, Ann Arbor, MI 48109.
Submitted for publication: April 30, 1984.
282
From the Section of Thoracic Surgery, The University of
Michigan Medical Centers, Ann Arbor, Michigan
also the appropriateness of THE as a "cancer operation."
Our approach to carcinoma involving the cervicothoracic
esophagus has been discussed previously.3 This report
reviews our experience with 100 patients with carcinoma
involving the intrathoracic esophagus. The efficacy of
THE as a palliative procedure, as well as its ability to
achieve apparent cure in patients with esophageal car-
cinoma, is emphasized.
Materials and Methods
During the past 7 years, THE without thoracotomy,
as described previously,"4 has been performed in 100
patients with carcinoma of the thoracic esophagus (7 upper
thoracic, 45 middle third, and 48 distal third). Upper
third tumors were defined as those extending from the
thoracic inlet to the level of the carina, or from approx-
imately 19 cm to 25 cm from the upper incisors at en-
doscopy. Middle third tumors involved the esophagus
from the level of the carina to a point approximately 5
cm above the esophagogastric junction, roughly 25-35
cm from the incisors. Distal third tumors involved the
esophagus from 35 to 40 cm from the incisors. Histo-
logically, all seven of the upper third carcinomas were
squamous cell. Of the 45 middle third tumors, 38 (84%)
were squamous cell carcinoma, and seven (16%) were
adenocarcinomas. This distribution was reversed among
the 48 distal esophageal tumors, where 41 (85%) were
adenocarcinomas and seven (15%) were squamous cell.
Among these 100 patients, 80 were men and 20 were
women, ranging in age from 38 to 92 years, with an
average of 62 years. Twenty-one of these patients were
70 years of age or older. Dysphagia was the predominant
presenting complaint in all but four patients, and the
average duration of symptoms before diagnosis was 3
months. Seventy-one patients had experienced weight loss
that averaged 10.5 kg.
Vol. 200 * No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY 283
The preoperative assessment included a barium swallow TABLE 1. TNM Classification for Postsurgical Resection
examination and esophagoscopy with biopsy in all pa- Staging ofEsophageal Carcinoma*
tients. Those with mid or upper third tumors underwent Definitions
bronchoscopy to assess possible tracheobronchial inva- Primary tumor (T)
sion. High grade obstructing tumors were dilated enough T1-Tumor invading mucosa or submucosa but not muscularis
T2-Tumor invading but not through muscularis
to enable passage of a feeding tube, and enteral alimen- T3-Tumor invading entire thickness of muscularis into
tation was instituted via the nasogastric tube in all patients adjacent tissue
unable to swallow an adequate caloric intake. Intravenous Regional lymph nodes (N)
No-Regional nodes not involved
hyperalimentation was not used routinely in any patient. N,-Unilateral regional nodes involved
When warranted by dehydration, marked weight loss, or N2-Bilateral regional nodes involved
N3-Extensive multiple regional nodes involved
pulmonary sepsis secondary to aspiration from the Distant metastasis (M)
esophageal obstruction, up to 2 weeks were invested before Mo-No distant metastasis
surgery administering adequate calories through a feeding MI-Distant metastasis
tube, encouraging ambulation, and delivering intensive Classification
Stage I-T1, No, Mo
pulmonary physiotherapy in association with a program Stage II-TI, N1, N2; MO T2, NO-N2; MO
of total abstinence from cigarette smoking. Approximately Stage III-T3, any N, MO Any T, N3, MO
1 unit of blood was transfused before surgery for every
Stage IV-Any T, any N, Ml
10 lbs of weight loss the patient had experienced. * Modified from the Manual for Staging
of Cancer, second edition.
After THE, the stomach was used to replace the esoph- American Joint Committee on Cancer. Edited by Beahrs P and Myers
MH. J. B. Lippincott Co., Philadelphia, PA, 1983; 61-72.
agus in 96 of these patients, the four requiring long seg-
ment colonic interposition having undergone prior gastric
resection for peptic ulcer disease. The esophageal sub- racotomy for intrathoracic hemorrhage either during the
stitute was positioned in the posterior mediastinum in operation or in the acute postoperative period.
the original esophageal bed in 94 patients, four patients
undergoing placement of the stomach and two the colon
in the retrosternal position due to concern that residual Complications
posterior mediastinal tumor might subsequently result in
recurrent obstruction. Intraoperative. Entry into one or both pleural cavities
was apparent on routine inspection of the pleura through
Sampling of accessible subcarinal, paraesophageal, and
celiac axis lymph nodes was routine, but no attempt was the hiatus after completion of the esophagectomy in 63
made to perform an en bloc wide resection of the esoph- patients and was treated with placement of a chest tube(s)
agus and its contiguous lymph node bearing tissues. In
before positioning the esophageal substitute in the chest.
53% of these patients, as assessed by the operative findings, Two patients required a splenectomy because of intra-
local tumor invasion or distant lymph node metastases operative injury to the spleen. Two tracheal lacerations
precluded a "curative" resection. In 47%, however, gross occurred during resection of midesophageal carcinomas.
total removal of all palpable or visible tumor and adjacent One, involving the high membranous trachea, was ex-
lymph nodes was achieved and was felt to represent a posed and repaired through a partial upper sternal split.
potentially curable procedure. Nevertheless, postsurgical The other, involving the membranous carina, was man-
tumor node metastasis (TNM) staging ofthese carcinomas
aged by guiding the endotracheal tube through the left
based upon histologic examination of the resected spec- mainstem bronchus, administering one lung anesthesia
imen (Table 1) indicated that only five patients had Stage as a substernal gastric bypass was completed, and then
I carcinomas (Table 2). In 76 patients the carcinomas
were transmurally invasive into periesophageal tissue on TABLE 2. Postsurgical Resection Staging of 100 Intrathoracic
histologic examination, and in another eight patients, al- Esophageal Carcinomas
though the tumor was invading the esophageal muscle
Tumor Site
but had not penetrated it completely, extensive regional
or distant lymph node metastases were present (Stage III Upper Middle Distal
or Stage IV tumors). Third Third Third Total
TNM Stage
Results I 0 3 2 5
II 0 6 5 11
III 4 30 37 71
There were no intraoperative deaths. Measured intra- IV 3 6 4 13
operative blood loss ranged from 125 to 250 ml and 48 100
Total 7 45
averaged 881 ml (Table 3). No patient required a tho-
 ORRINGER Ann. Surg. * September 1984
284
TABLE 3. Intraoperative Blood Loss with Transhiatal Esophagectomy from mediastinal or retroperitoneal abscess (2), and re-
Blood Loss (ml) spiratory insufficiency secondary to severe chronic ob-
structive pulmonary disease (1). One of the two patients
Site Number Range Average who aspirated retained intrathoracic gastric contents did
Upper third 7 300-2500 943 so when she received cleansing purgatives after having a
Middle third 45 125-2000 766 normal postoperative barium swallow on the tenth post-
Lower third 48 260-2500 976 operative day. The two deaths from sepsis occurred in
Total 100 125-2500 881 patients with extensive midthird carcinomas. In one, be-
cause of residual posterior mediastinal tumor after frac-
turing the primary mass away from the prevertebral fascia,
repositioning the patient for a right thoracotomy through the stomach was positioned retrosternally. A subsequent
which the tracheal tear was closed. Both of these latter anastomotic leak was drained but the patient succumbed
two patients had uneventful postoperative courses. to respiratory insufficiency and sepsis. At postmortem
Postoperative. Left recurrent laryngeal nerve paresis examination, there was a large posterior mediastinal ab-
with resulting hoarseness occurred in 31 patients. The scess. The second patient underwent palliative THE in
hoarseness resolved spontaneously within 2 to 12 weeks the presence of hepatic metastases found at operation.
of operation in all but four patients, three of whom re- After surgery, he developed deep thrombophlebitis of the
quired Teflon injection of the paralyzed vocal cord. This leg, progressive ascites, and sepsis. At autopsy a large
complication was initially thought to be an unavoidable retroperitoneal abscess was found. Retrospectively, disease
consequence of blunt transhiatal dissection, which was was too extensive in both of these latter patients to persist
postulated to traumatize the recurrent laryngeal nerve with the esophagectomy. The patient who succumbed to
where it loops beneath the aortic arch in the chest. In severe chronic obstructive pulmonary disease could not
our last consecutive 31 patients, however, meticulous be weaned from the ventilator after surgery, underwent
avoidance of any retractor against the tracheoesophageal a tracheostomy, and was able to swallow soft foods until
groove during the cervical portions of the operation has she developed pneumonia and died after a 3-month hos-
resulted in a striking decrease in the incidence of post- pitalization.
operative hoarseness, which has occurred in two patients. Follow-up
Two patients, both with upper third esophageal carci-
nomas, developed a chylothorax that ultimately required
The 94 survivors of THE were discharged after an av-
a limited thoracotomy and ligation of the thoracic duct erage hospitalization of 14 days. Seventy patients (74%)
for control. There were five cervical esophagogastric were discharged between 11 to 14 days after operation,
anastomotic leaks, three in 92 patients (3%) in whom the and 10 (11%) between 15 to 21 days. Thus, 85% of the
stomach was positioned in the posterior mediastinum in operative survivors were discharged within 3 weeks of
the original esophageal bed, and two in four patients (50%) operation. Postoperative radiation and/or chemotherapy
in whom the stomach was positioned substernally. were generally recommended for patients who were be-
lieved to have had palliative resections. Such adjuvant
therapy was typically administered under the direction
Mortality of physicians located near the patients' homes following
There were six hospital deaths for an overall mortality their discharge from our medical center. Thus, 23 patients
of six per cent. The causes of death included pulmonary (25%) received postoperative chemotherapy, 16 patients
embolus (1), massive aspiration pneumonia (2), sepsis (17%) radiation therapy, and seven patients (7%) both
radiation and chemotherapy. The remaining 48 patients
(51%) received no postoperative adjuvant therapy.
TABLE 4. Actuarial Survival Following Transhiatal Esophagectomy The current status of all 94 patients is known, and
for Intrathoracic Esophageal Carcinoma their actuarial survival is shown in Table 4. Overall, at
Per cent Survival After Operation the time of this report, 52% have lived 12 months; 32%,
24 months; 22%, 36 months; and 17%, 48 months. Be-
6 12 24 36 48 cause postoperative adjuvant therapy was not adminis-
mos mos mos mos mos tered using a randomized design, and because the therapy
Site Number was not standardized, the effect of adjuvant therapy upon
Upper third 7 71 54 survival in this group is difficult to determine. Statistically,
Middle third 40 77 41 21 17
however, there was no significant difference in survival
Lower third 47 88 62 48 31 26
between those who received postoperative adjuvant che-
Total 94 82 52 32 22 17 motherapy, radiation therapy, or both and those who did
Vol. 200 . No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY 285
not. All but three patients who have died since THE have TABLE 5. The Effect of Tumor Stage on 12- and 24-Month Survival
had documented or clinically presumptive evidence of Following Transhiatal Esophagectomy for Intrathoracic
Esophageal Carcinoma-94 Patients
widespread metastatic esophageal carcinoma.
As expected, the stage of the resected tumor proved to Per cent Survival
be an important determinant ofsurvival in these patients, Tumor
Stage Number 12 Mos 24 Mos
those with Stage I and II tumors living considerably longer
than those with Stage III and IV disease (Table 5). Since I and II 15* 83 54
most of the middle third tumors were squamous carci- III 68 48 28
IV I1 34 0
nomas, and most of the distal third tumors were ade-
nocarcinomas, however, a more meaningful statistical * Stage I and II tumors are considered together because of the small
number of patients with Stage I disease (5). These differences in 12-
analysis compares the effect of tumor stage, as well as and 24-month survival between the three stage groups are statistically
tumor location, upon survival (Table 6). Approximately significant (p-value 0.0069).
50% of patients with Stage I and II tumors of both the
middle and distal esophagus survived 24 months. The
12-month and 24-month survival of patients with Stage cervical anastomotic suture line recurrence prior to their
III tumors, however, was considerably better for distal deaths from carcinomatosis. Fifteen patients (16%) have
third as compared to middle third carcinomas. acknowledged experiencing some postoperative regurgi-
Fourteen ofthe 94 operative survivors (15%) have lived tation of intrathoracic gastric contents, primarily on as-
24 months or more. Among these "long-term" survivors, suming the recumbent position shortly after eating. No
three have died of metastatic disease after 29, 31, and 38 patient, however, has developed pulmonary complications
months, one died of lymphoma after 29 months, and one of reflux, and none has complained of heartburn. Tran-
died of a myocardial infarction after 24 months. This sient postvagotomy diarrhea, generally well-controlled
latter patient was an 80-year-old woman who underwent with diphenoxylate, has occurred in 41 (44%) of these
THE for a Stage III distal third adenocarcinoma arising patients. No patient has had difficulty with emptying of
in a Barrett's esophagus and received chemotherapy after the intrathoracic stomach following pyloromyotomy.
surgery for 1 year. She had no residual tumor at post-
mortem examination. Another patient died of a stroke Discussion
after 39 months and was clinically tumor-free at the time
of his death. One patient has metastatic adenocarcinoma In performing THE, after mobilization of the visceral
from his esophagogastric junction primary after 54 esophageal substitute (generally stomach) is complete, re-
months. The remaining patients are alive and clinically sectability of the esophagus is determined by palpation
tumor-free after 30, 34, 41, 60, 68, 72, and 81 months, through the diaphragmatic hiatus. The surgeon must be
respectively. The first three of these seven patients had prepared to perform a thoracotomy or esophageal bypass
midthird esophageal carcinomas (Stages I, II, and III, if extensive fixation of the tumor-containing portion of
respectively), and the latter four had distal third esophageal the esophagus to adjacent structures is encountered.
adenocarcinomas (Stages III, III, II, and I, respectively).
Following discharge from the hospital, patients who TABLE 6. The Effect of Tumor Stage and Location on 12- and 24-
have undergone THE for carcinoma are seen in follow- Month Survival Following Transhiatal Esophagectomy for
up after 2 weeks, then at 3-month intervals for 2 years, Intrathoracic Esophageal Carcinoma in 87 Patients*
and yearly thereafter. Outpatient Hurst-Maloney bougi-
Middle Third
enage of the cervical anastomosis is utilized very liberally Carcinomas Distal Third Carcinomas
if any complaint of cervical dysphagia is elicited in post-
operative follow-up. Thus, of the 94 operative survivors, Per cent Per cent
Survival Survival
42 (45%) have undergone such outpatient dilations for
cervical dysphagia, generally between 1-3 times during Tumor 12 24 12 24
the first six postoperative months, but only six have de- Stage Number Mos Mos Number Mos Mos
veloped true fibrotic anastomotic strictures necessitating I and II 8 71 53 7 100 50
regular bougienage. One patient with postoperative re- III 26 29 12 38 60 42
current laryngeal nerve paralysis experienced severe sec- IV 6 33 0 2 0 0
ondary cricopharyngeal motor dysfunction and never re- * The seven
patients with upper third carcinomas are excluded from
gained his ability to swallow by the time of his death this analysis due to their small number. The differences in 12- and 24-
from metastases after 5 months. All but these latter seven month survival between the three stage groups of middle third carcinomas
are not quite statistically significant (p-value 0.1197). For distal third
patients have been able to swallow an unrestricted diet tumors, however, the differences between the three stage groups are
comfortably. Two patients developed dysphagia from significant (p-value 0.0019).
286
Among our last 104 consecutive patients with carcinoma
of the intrathoracic esophagus, however, THE has been
possible in 100, local tumor extension necessitating stan-
dard transthoracic esophagectomy or esophageal bypass
in four. It is conceivable that our relatively high resect-
ability rate using the technique of THE is related to the
general socioeconomic level and availability of medical
care for our patients, relatively few presenting with severe
cachexia and huge tumors. Nevertheless, in our expeni-
ence, even relatively large intrathoracic esophageal car-
cinomas are resectable through the hiatus, if necessary
fracturing the tumor away from the prevertebral fascia
or other adjacent mediastinal structures. The addition of
a partial upper sternal split facilitates dissection under
direct vision of upper third esophageal carcinomas, which
may be adherent to but not invading the trachea.5
It is apparent from our experience with both benign
and malignant esophageal disease that the normal stomach
readily reaches above the level of the clavicles for a tension- tients
free cervical esophagogastric anastomosis. Regardless of lymph node dissection- 17% for middle third tumors
the visceral esophageal substitute used, the posterior me-
diastinal route in the original esophageal bed is the pre-
ferred location because: (1) it is the shortest distance be- series
tween the neck and abdomen; (2) subsequent esophageal
dilations, required,
if are made difficult by the anterior cinoma carries a mortality that is generally between 15-
displacement of the anastomosis that occurs when the
stomach or colon are positioned substernally in the an-
terior mediastinum; and (3) the incidence of anastomotic
leak is increased when a cervical esophagogastric anas-
tomosis is positioned in the anterior neck as opposed to
the more posterior location in the esophageal bed.6
The most frequent complications of transhiatal esoph-
agectomy are relatively minor. A pleural tear occurs in
nearly two-thirds of the patients, but a chest tube has
seemed a small price to pay for avoidance of a thora-
cotomy. Recurrent laryngeal nerve injury can be a dev-
astating complication after esophagectomy, not only be-
cause of the resulting hoarseness but also because of im-
paired swallowing and secondary aspiration that may
occur. This complication, however, can usually be averted
by avoiding cervical retraction on the tracheoesophageal
groove. The only major complications of THE we have
encountered are intraoperative tracheal laceration (2 pa-
tients) and postoperative chylothorax (2 patients), both
in patients with middle or upper third esophageal car-
cinomas. Uncontrollable thoracic bleeding has not oc-
curred in any of our patients. Clearly, however, the po-
tential for such complications of esophagectomy, regard-
less of the operative approach, emphasizes the need for
a sound knowledge of thoracic surgical anatomy and
technique. The fact that a thoracotomy is unnecessary
in most patients undergoing an esophagectomy does not
mitigate the requirement of thoracic surgical training.
THE for carcinoma has been criticized for denying an
ORRINGER Ann. Surg. September 1984
adequate esophageal resection and formal lymph node
dissection to patients with potentially curable tumors.7'8
However, few American or European surgeons subscribe
to the concept of radical esophagectomy with a formal
en bloc dissection of contiguous lymph node bearing tis-
sues, pleura, and abdominal lymphatics.9Y0 In the vast
majority of patients with esophageal carcinoma, the goal
of esophagectomy is palliation, not cure, and if the latter
should somehow be achieved, it is more a function of
individual tumor biology and host resistance rather than
the extent of the resection performed. Skinner has recently
reported his results of "radical esophagectomy and en
bloc dissection" in the treatment of 80 patients with car-
cinoma of the esophagus and cardia.'0 His 29 patients
with midesophageal tumors had a 3-year actuarial survival
of 14%, while the 37 patients with lower third tumors
had a 3-year survival of 33%. These data do not differ
appreciably from the 3-year actuarial survival in our pa-
undergoing THE without attention to a formal
and 31% for distal third tumors.
With the notable exception of a few recently reported
in which the hospital mortality has been less than
5%, 11-13 esophageal resection and reconstruction for car-
40%.14,5 Giuli and Gignoux, presenting the results in
2400 patients with esophageal carcinoma operated upon
in multiple European hospitals, report a mortality for
esophagectomy of 30%.16 Similarly, Earlam and Cunha-
Melo, in an extensive literature review, report a hospital
mortality of 33.3% in 83,783 esophagectomies.'7 THE
without thoracotomy is clearly less of a physiologic insult
to the debilitated patient with esophageal carcinoma than
the traditional combined thoracic and abdominal ap-
proach used for esophageal resection and reconstruction.
Twenty-one per cent of our patients were 70 years of age
or older, and seven of these were between 75 to 92 years
of age. In more than one-half of these elderly patients,
because of marked debility, a thoracotomy would not
even have been considered. Our overall hospital mortality
of six per cent, as well as the fact that 85% of our patients
surviving operation left the hospital within 3 weeks of
operation, attest to the merits of THE in providing efficient
and relatively safe palliation in the patient with carcinoma
of the thoracic esophagus.
Acknowledgment
The author is indebted to Kenneth E. Guire, M.S., Senior Research
Associate, University of Michigan School of Public Health, for his sta-
tistical analysis of this data.
References
1. Orringer MB, Sloan H. Esophagectomy without thoracotomy. J
Thorac Cardiovasc Surg 1978; 76:643-654.
Vol. 200 * No. 3 TRANSHIATAL ESOPHAGECTOMY WITHOUT THORACOTOMY
2. Orringer MB, Orringer JS. Transhiatal esophagectomy without
thoracotomy-a dangerous operation? J Thorac Cardiovasc Surg
1983; 85:72-80.
3. Orringer MB, Sloan H. Anterior mediastinal tracheostomy-indi-
cations, techniques, and clinical experience. J Thorac Cardiovasc
Surg 1979; 78:850-859.
4. Orringer MB. Transhiatal blunt esophagectomy without thoracot-
omy. In Cohn LH, ed. Modern Techniques in Surgery-Car-
diothoracic Surgery. Installment IX. Mt. Kisco, NY: Futura
Publishing Co, 1983; 1-21.
5. Orringer MB. Partial median sternotomy: anterior approach to the
upper thoracic esophagus. J Thorac Cardiovasc Surg 1984;
87: 124-129.
6. Orringer MB. Substernal gastric bypass of the excluded esophagus-
results of an ill-advised operation. Surg, in press.
7. Parker EF. Discussion of Orringer MB and Sloan H. Esophagectomy
without thoracotomy. J Thorac Cardiovasc Surg 1978; 76:652-
653.
8. Skinner DB. Discussion of Orringer and Sloan H. Esophagectomy
without thoracotomy. J Thorac Cardiovasc Surg 1978; 76:652.
9. Logan A. The surgical treatment of carcinoma of the esophagus
and cardia. J Thorac Cardiovasc Surg 1963; 46:150-161.
DISCUSSION
DR. ROBERT E. CONDON (Milwaukee, Wisconsin): I want to confine
my remarks to the surgical management of the difficult problem of
adenocarcinoma of the cardia and of the distal esophagus.
Carcinoma of the cardia generally presents, as does squamous esoph-
ageal cancer, with symptoms, primarily, of obstruction. The biology of
the lesion is that of a gastric cancer, with a poor response to radiation
and no effective chemotherapy, leaving surgical therapy as the only
means of palliation and perhaps cure.
When seen, these patients usually have very bulky lesions and they
often have already involved the adjacent diaphragm, but metastases to
the liver and to the distal lymph nodes occur much later in the course
of the disease and, therefore, meaningful palliation is a true surgical
potential.
The unique feature ofadenocarcinoma ofthe cardia is that it regularly
spreads submucosally in the esophagus, and so unless an extensive
esophageal resection is undertaken, the disease will not be satisfactorily
controlled.
The typical approach to the management of adenocarcinoma of the
cardia has been to do a resection of the proximal stomach and the distal
esophagus, with an esophagogastrostomy in the chest conducted through
a left thoracotomy. That approach has two problems: (1) it does not
encompass all of the submucosal spread of the disease; and (2) if you
get an anastomotic leak in the chest, the potential for disaster is certainly
present. Further, if the patient survives more than 6 months, reflux
esophagitis is a problem.
Because of these considerations, we abandoned this more traditional
approach 4 years ago and switched to total thoracic esophagectomy in
continuity with resection of the upper half to two-thirds of the stomach
for carcinoma of the cardia. We have done it in the manner as outlined
by Dr. Orringer and in the last 4 years we have treated 22 patients. We
have had no operative mortality. We have reconstructed all of these
patients by mobilizing the distal stomach remnant to the neck, then
conducting a cervicoesophagogastrostomy.
The 4-year survival is 25%, and the postoperative course in these
patients is certainly more benign than it is after a thoracotomy. The
consequences of an anastomotic leak in the neck are trivial compared
to the problem of an anastomotic leak in the chest.
We have found that use of a two-team approach, one team doing the
cervical portion of the operation and another doing the abdominal por-
tion, has markedly shortened our operative time. The same concept
that we use in resecting the rectum in an abdominoperineal resection-
it has done more than cut the time in half. It has cut it to about one-
third.
I would like to ask Dr. Orringer if he uses the two-team approach
for the management of his patients, and for any amplifying remarks he
287
10. Skinner DB. En bloc resection for neoplasms of the esophagus and
cardia. J Thorac Cardiovasc Surg 1983; 85:59-71.
11. Akiyama H, Tsurumaru M, Kawamura T, Ono Y. Principles of
surgical treatment for carcinoma of the esophagus: analysis of
lymph node involvement. Ann Surg 1981; 194:438-446.
12. Ellis FH Jr, Gibb SP. Esophagogastrectomy for carcinoma: current
hospital mortality and morbidity rates. Ann Surg 1979; 190:699-
705.
13. Piccone VA, LeVeen HH, Ahmed N, Groberg S. Reappraisal of
esophagogastrectomy for esophageal malignancy. Am J Surg 1979;
137:32-38.
14. Ellis FH Jr. Carcinoma of the esophagus. Cancer 1983; 33:264-
281.
15. Postlethwait RW. Complications and deaths after operations for
esophageal carcinoma. J Thorac Cardiovasc Surg 1983; 85:827-
831.
16. Giuli R, Gignoux M. Treatment of carcinoma of the esophagus-
retrospective study of 2400 patients. Ann Surg 1980; 192:44-
52.
17. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma.
I. A critical review of surgery. Br J Surg 1980; 67:381-390.
may have from his extensive experience with the management of ad-
enocarcinoma of the cardia and the esophagus.
Dr. Stem, I am reminded by our President's Address this morning
that sometimes we are slow to adopt useful new operations. I remind
you all that this operation was introduced half a century ago by George
Grey Turner and, although Professor Turner continued to use it oc-
casionally throughout his active professional lifetime, it has only been
more recently that surgeons such as Dr. Orringer and Dr. Akiyama have
brought this useful operation back into our consciousness.
I believe there is a place for this operation, and I support its use for
the indications that Dr. Orringer has outlined.
DR. WILLIAM E. NEVILLE (Newark, New Jersey): After Dr. Ravitch's
Presidential Address, I may be treading on perilous ground for the future,
but I arise with mixed emotions to discuss this fine paper by Dr. Orringer.
On the one hand, this operation is a tribute to his surgical dexterity,
but on the other hand, it is not one which I would do, nor would I let
my residents do.
All of us who perform esophagectomy for cancer of the esophagus
realize how difficult it is to perform an adequate cancer operation with
the chest open. Now we are supposed to do this blindly, by feel. Ad-
mittedly, there are certain technical mnaneuvers that can be expeditiously
performed blindly by all of us, in the dark, but this is done for pleasure,
and in situations where we are well versed in the anatomy. (Laughter)
In the operation for esophageal cancer, none of these amenities are
available.
Another factor enters into the universal acceptance of this operation,
and that is the impact this can have on malpractice lawyers. His list of
complications are indefensible in court because this is not the standard
technique, nor the state of art, which one should employ for cancer of
the esophagus at the moment. I personally know offive cases undergoing
litigation at the present time due to an exsanguinating hemorrhage in-
traoperatively from avulsion of the aortic wall during removal of the
esophagus. I personally have turned down two of them for being an
expert witness for the defendant because I could not see my way clear.
On the other hand, what he says, very clearly, is true: In his hands
it is safe. The survival is almost as good as that reported for transthoracic
esophagectomy. It may be that this is the way to go on patients who
for some reason or another cannot tolerate a thoracotomy. However,
in these circumstances, I firmly believe that the method of choice is to
bypass the esophagus extrathoracically, and let the patient eat normally
for what little time he has left.
A question to Dr. Orringer that was not brought out in the abstract
is: What is his role in preoperative therapy or chemotherapy? In our
institution, Ben Rush and I give the patient the benefit of preoperative
x-ray and collaborate-which was brought out by the previous discus-