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.