Transhiatal versus Ivor-Lewis oesophagectomy: Is there a difference?

Introduction: Curative oesophageal resection for carcinoma may be carried o ut by either the transhiatal or the Ivor-Lewis transthoracic technique. The aims of this study were to compare the morbidity, 30-day mortality and lon g-term survival of the two techniques in the treatment of oesophageal carci noma and to provide data to calculate the sample sizes for a prospective ra ndomized trial. Methods: Results from 44 series published between January 1986 and December 1996 were reviewed. Thirty-three papers reported results on 2675 patients having transhiatal (THO) and 29 papers reported results on 2808 patients ha ving Ivor-Lewis oesophagectomy (ILO). Results: The two groups were comparable in terms of age, sex and stage of t he disease. There was no apparent difference in postoperative morbidity bet ween the two groups with respect to respiratory complications (24% for THO, 25% for ILO), cardiovascular complications (12.4% for THO, 10.5% for ILO), wound infection (8.8% for THO, 62% for ILO) and chylothorax (2.1% for THO, 3.4% for ILO). The transhiatal group appeared to have a higher incidence o f anastomotic leaks (16% for THO, 10% for ILO), anastomotic strictures (28% for THO, 16% for ILO) and recurrent laryngeal nerve injuries (11.2% for TH O, 4.8% for ILO). The 30-day mortality was 6.3% for transhiatal and 9.5% fo r Ivor-Lewis oesophagectomy. Overall long-term survival at 5 years was simi lar (24% for THO, 26% for ILO). Conclusions: The surgical approach to oesophagectomy was not an important d eterminant of morbidity and long-term survival in patients with oesophageal carcinoma. Transhiatal oesophagectomy was associated with a higher inciden ce of anastomotic complications and recurrent laryngeal nerve injury. Ivor- Lewis oesophagectomy had a higher mortality. In order to demonstrate a sign ificant difference in morbidity or long-term survival between the two techn iques 3100 patients would be required in each arm of a prospective randomiz ed trial.