Thoracoabdominal Esophagectomy: Then and Now

BACKGROUND:Open approaches for esophagectomy are often still useful, among which, left thoracoabdominal esophagectomy (TAE) is poorly understood and often criticized. Hence, we examined TAE's worldwide utilization, survival, and present-day utilization and outcomes at our institution compared to contemporary national averages. METHODS:The Worldwide Esophageal Cancer Collaboration database includes 8,854 patients who underwent esophagectomy for cancer between 2005 and 2014, a period when TAE was our center's most common approach. Two propensity-matched models were constructed: 1) worldwide TAE vs. worldwide non-TAE (751 matched pairs) and 2) our high-volume center vs. worldwide non-TAE (273 matched pairs). All-cause mortality was compared between matched groups. Institutional TAE data from 2017-2021 were assessed for present-day utilization and outcomes. RESULTS:Worldwide, propensity-matched patients undergoing TAE had a median of 20 lymph nodes resected vs. 17 following non-TAE (P < .0001). Five-year survival was 34% for worldwide TAE vs. 42% for worldwide non-TAE groups (P=.04). Three-year matched survival was 52% for high-volume TAE compared to 54% for worldwide non-TAE groups (P=0.10). From 2017-2021 at our institution, 90 (26%) of 346 esophagectomies were performed via TAE. Five (5.6%) developed pneumonia, with 88 (98%) alive at 30-days, comparable to contemporary Society of Thoracic Surgeons averages. CONCLUSIONS:When performed as the primary approach in high volumes, TAE can be performed with comparable outcomes to non-TAE with low morbidity. Present-day, we find TAE is most useful in patients with truncal obesity, prior abdominal operations, and locally advanced cardia tumors with potential for variable extent of resection.