En Bloc vs Transhiatal Esophagectomy for Stage T3 N1 Adenocarcinoma of the Distal Esophagus

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Abstract
Controversy persists regarding the extent of resection necessary for cure of esophageal adenocarcinoma. Several retrospective studies1-3 have shown a benefit to the more extensive node dissection accomplished with transthoracic en bloc esophagectomy (EBE) compared with transhiatal esophagectomy (THE). These studies have been criticized as having selection bias and inaccuracy in preoperative staging. Performance of a more complete node dissection also results in the potential for stage migration. A recent prospective randomized controlled trial4 compared transthoracic EBE with THE. The results were inconclusive but showed a trend toward better survival with transthoracic EBE.4 This trial eliminated many of the criticisms of the retrospective studies but included patients with various stages of disease. This broad inclusion may have obscured the benefits of systematic node dissection by the presence of patients with early-stage disease who did not need a formal lymphadenectomy and those with advanced disease and extensive lymph node metastases who were not curable by surgery alone. An alternative approach to compare transthoracic EBE with THE would be to perform a retrospective case-control study between nonrandomized patients with similarly sized transmural tumors (T3) and lymph node metastases (N1). The aim of the present study is to determine whether patients with locally advanced (T3 N1) (according to the American Joint Committee on Cancer TNM staging system) esophageal cancer benefit from transthoracic EBE.