En bloc vs transhiatal esophagectomy for stage T3 N1 adenocarcinoma of the distal esophagus

Hypothesis: En bloc esophagectomy (EBE) provides improved survival over transhiatal esophagectomy (THE) in patients with similarly sized transmural tumors (T3) and lymph node metastases (N1). Design: A retrospective case-control study of 2 methods of esophageal resection for cancer. Settings: University hospital (tertiary referral center for esophageal disease). Patients: There were 49 patients (27 who underwent EBE and 22 who underwent THE) with similar T3 N1 disease and the following matched criteria: tumors of similar size and location, more than 20 lymph nodes in the surgical specimen, RO resection, no previous chemotherapy or radiation therapy, and follow-up until death or for a minimum of 5 years. Main Outcome Measures: Survival adjusted for differences in demographic and patient characteristics. Results: The number of nodes harvested was greatest after EBE vs THE (median, 52 vs 29 [range, 21-85 vs 20-60]; P<.001). The median number of involved nodes was similar after EBE vs THE (median, 5 vs 7 [range, 1-19 vs 1-16]). The only 2 independent factors that affected survival in a Cox analysis were the number of involved lymph nodes (P=.01) and the type of resection (P=.03). Patients who underwent EBE had a survival benefit over those who underwent THE (P=.01). The survival benefit of EBE was seen only in patients with fewer than 9 involved lymph nodes (P<.001). Conclusions: En bloc esophagectomy confers a better survival than THE in patients with T3 N1 disease and fewer than 9 lymph node metastases.