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The Journal of Thoracic and Cardiovascular Surgery, Vol 105, 265-276, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
MB Orringer, B Marshall and MC Stirling
Transhiatal esophagectomy has been performed in 583 patients with diseases
of the intrathoracic esophagus: 166 (28%) benign and 417 (72%) malignant
(6% upper, 28% middle, and 66% lower third and cardia). The benign
esophageal diseases included strictures (40%); neuromotor
dysfunction-achalasia (24%), esophageal spasm (8%); recurrent
gastroesophageal reflux (16%); acute perforation (5%); acute caustic injury
(2%); and others (3%). Among the patients with benign disease, 60% had
undergone at least one prior esophageal operation. Transhiatal
esophagectomy was possible in 97% of patients in whom it was attempted, 19
patients (13 with benign disease and 6 with carcinoma) requiring addition
of a thoracotomy for esophageal resection. Esophageal resection and
reconstruction were performed in a single operation in all but 5 patients.
The esophageal substitute was positioned in the posterior mediastinum in
the original esophageal bed in 96%. Stomach was used to replace the
esophagus in 553 patients (95%) and colon in 28 (5%) who had undergone
prior gastric resections. Overall hospital mortality was 5% in patients
with benign disease and 5% in those with carcinoma. There was 1
intraoperative death caused by uncontrollable hemorrhage. Complications
included intraoperative entry into a pleural cavity necessitating a chest
tube (74%), anastomotic leak (9%), recurrent laryngeal nerve paralysis
(3%), and chylothorax and tracheal laceration (< 1% each). Three
patients required reoperation for mediastinal bleeding. Average
intraoperative blood loss was 875 ml (1023 ml for benign disease and 817 ml
for carcinoma). Of the surviving patients, 88% were discharged able to
swallow within 3 weeks of operation and 78% within 2 weeks. The actuarial
survival of the patients with carcinoma is similar to that reported after
more traditional transthoracic esophagectomy. Among patients with benign
disease, good or excellent functional results have been achieved in nearly
70% after a cervical esophagogastric anastomosis. Although approximately
44% have required one or more anastomotic dilations within 1 to 3 months of
operation, true anastomotic strictures have developed in 10%. Clinically
troublesome nocturnal reflux has occurred in 3%. Transhiatal esophagectomy
is feasible in most patients requiring esophageal resection for either
benign or malignant disease and is a safe, well-tolerated operation if
performed with care and for the proper indications.
ARTICLES
Transhiatal esophagectomy for benign and malignant disease
Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109.
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