Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer

Background: The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO. Methods: This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion. Results: Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1.1 versus 3.2 per cent for THO and TTO respectively; P=0.110) and in-hospital stay (14 versus 17 days respectively; P<0.001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1.07, 95 per cent c.i. 0.84 to 1.36) or time to tumour recurrence (HR 0.99, 0.76 to 1.29) between the two operations. Local tumour recurrence patterns were similar (22.8 versus 24.4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage. Conclusion: There was no difference in survival or tumour recurrence for TTO and THO. Surgical approach makes little difference to long-term outcomes