Total thoracic oesophagectomy for oesophageal carcinoma: has it been worthit?

Objective: Anastomotic recurrence is a major cause of late mortality follow ing oesophago-gastrectomy (OG) for carcinoma of the oesophagus and oesophag o-gastric junction using either the Ivor Lewis or left thoraco-abdominal ap proach with intra-thoracic anastomosis. The aim of this study was to determ ine whether the more extensive total thoracic oesophagectomy (TTO) with cer vical anastomosis would reduce the: anastomotic recurrence rate while maint aining acceptable operative morbidity and mortality. Methods: From January 1988 to December 1996, 108 total thoracic oesophagectomies and 66 oesophago -gastrectomies were performed with curative intent in 174 patients (125 mal es, mean age 62.4 years) with carcinoma (squamous cell carcinoma in 34 and adenocarcinoma in 140) of the middle (31 patients) and lower (34 patients) oesophagus and oesophago-gastric junction (99 patients). Results: Minor com plications occurred in 37 (34%) total thoracic oesophagectomy and 18 (27%) oesophago-gastrectomy patients, major complications in 15 (14%) and 5 (8%) and peri-operative death in 5 (4.6%) and 7 (11%) patients, respectively. An astomotic leakage occurred in 10 (9%) total thoracic oesophagectomy and 5 ( 8%) oesophago-gastrectomy patients, and was fatal in 1 (1%) and 4 (6%). The re was no incidence of tumour at or within 5 mm of the proximal limit in th e total thoracic oesophagectomy group and this was reflected in the complet e absence of anastomotic recurrence. In the oesophagogastrectomy group ther e was a positive proximal resection margin in 13 (20%) and 13 anastomotic r ecurrences (22% of peri-operative survivors). The 5-year survival (includin g operative mortality) was 29% for total thoracic oesophagectomy compared w ith 21% for the other techniques (P = 0.028 log rank test). Median survival was 25.2 months after total thoracic oesophagectomy and 15.8 after oesopha gogastrectomy. Conclusions: Total thoracic oesophagectomy can be performed in oesophageal cancer patients with comparable morbidity to that of lesser resections. Incomplete proximal resection and anastomotic recurrence did no t occur in this series of 108 total thoracic oesophagectomies and this is r eflected in an increased medium term survival. The improved survival is mos t apparent for tumours of the oesophago-gastric junction. (C) 1999 Elsevier Science B.V. All rights reserved.