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Jan Johansson, MD; Tom R. DeMeester, MD; Jeffrey A. Hagen, MD; Steven R. DeMeester, MD; Jeffrey H. Peters, MD; Stefan Öberg, MD; Cedric G. Bremner, MD

Arch Surg. 2004;139:627-633.

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.

Setting  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, R0 resection, no previous chemotherapy or radiation therapy, and follow-up until death or for a minimum of 5 years.

Main Outcome Measure  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).

Conclusion  En bloc esophagectomy confers a better survival than THE in patients with T3 N1 disease and fewer than 9 lymph node metastases.

From the Departments of Surgery, Lund University Hospital, Lund, Sweden (Drs Johansson and Öberg), and University of Southern California, Los Angeles (Drs T. R. DeMeester, Hagen, S. R. DeMeester, Peters, and Bremner).

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