Transhiatal Bests Left Thoracoabdominal for Some Esophogastric Tumors

Resection via the abdominal and transhiatal approach is superior to the left thoracoabdominal approach for cardia and subcardia tumors.

Orlando, FL—In a final survival analysis of the JCOG 9502 trial, Japanese investigators reported that resection via the abdominal and transhiatal approach (AT) is superior to the left thoracoabdominal (LT) approach for cardia and subcardia tumors.

The LT approach involves a large incision extending from the left side of the chest to the middle of the abdomen. With the AT approach, a smaller incision is made in the upper abdomen, which is less invasive but yields less space for the removal of lymph nodes. Whether the AT approach is inferior to the standard LT approach has not been clearly determined.

“We found that with the LT approach we see more of the tumor area, but it is much more aggressive and therefore leads to more complications without improving survival,” said Mitsuru Sasako, MD, of Hyogo College of Medicine, Nishinomiya, Japan.

He said that many such tumors are treated by thoracic surgeons, and they typically prefer the LT approach.

The multicenter JCOG 9502 study included 167 patients with adenocarcinoma, clinical T2-4 with esophageal invasion of 3 cm or less and no distant metastases. Between 1995 and 2003, patients were randomly assigned to either LT or AT plus lymph node dissection; adjuvant therapy was permitted upon recurrence.

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At a median follow-up of 7.7 years, 5-year survival was significantly higher in the AT group, 51% versus 37% for LT, as were other outcomes such as respiratory function, reported Sasako. This amounted to a 36% increased risk of death with the LT approach, he said. “We believe these are the best survival results to be obtained for these tumors,” Sasako told . He added that his group removes lymph nodes aggressively, which may favorably impact survival.

AT was superior to LT in all major subsets, he added, including sex, age, macroscopic type, Siewert type and histological type. For example, 5-year survival in patients with T2 disease was 66% with the AT approach and 57% with LT. In lymph node-negative patients, it was 86% versus 67%, respectively, and in patients with 7 to 15 positive nodes it was 50% versus 27%. He reiterated that such high survival rates are seldom seen in patients with extensive lymph node disease. Recurrence rates were similar as well, observed in 41 AT patients and 42 LT patients. The predominant site of recurrence for each was the lymph nodes.

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Postoperative respiratory function was significantly better with AT, as were rates of major complications such as anastomotic leak, pancreatic fistula, and abdominal abscess. Sasako said the percentage of patients experiencing any one of six major complications was only 22% with AT versus 42% with LT ( =.008), and that patients undergoing AT did not require more blood transfusions.

“The left thoraco-abdominal approach results in higher morbidity, such as more major complications and poorer post-operative respiratory function, without a survival benefit. It also possibly promotes early relapse,” Sasako said.

2010 GI Symposium Abstract 3