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Transhiatal oesophagectomy: treatment of choice for high-grade dysplasia

Department of Surgery, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK

Received 1 November 2008; received in revised form 24 March 2009; accepted 24 March 2009.

^_* Corresponding author. Tel.: +44 020 8642 6853; fax: +44 020 7340 5111. (Email: reza_mirnezami{at}yahoo.com).

Objective: To demonstrate that transhiatal oesophagectomy should remain the gold standard treatment for patients with high-grade dysplasia. Background: The conventional management of high-grade dysplasia of the oesophagus is surgery. Perceived high incidence of operative morbidity and mortality associated with oesophagectomy has led some to advocate alternative less invasive treatments such as endoscopic mucosal resection (EMR) and photodynamic therapy (PDT). We present our data on the use of transhiatal oesophagectomy for the management of high-grade dysplasia. Methods: Twenty-three patients underwent transhiatal oesophagectomy for biopsy-proven high-grade dysplasia in a high volume centre, between March 2000 and December 2006. Twenty-two were male and 1 female with a mean age of 63.5 years (±6.5). Staging was ascertained by gastroscopy, EUS and CT. Two patients had PET CT. ASA grade was I (2), II (14), III (6) and IV (1). Results: Clinical anastomotic leak occurred in two patients (9%); this was managed conservatively. Four patients required intensive care admission. Occult adenocarcinoma was found in 35% (8/23) of surgical specimens; there were no involved nodes present. No re-operations were required. Median length of stay was 15 days (10–69). Thirty-day and in-hospital mortality was zero. There was one case of locally recurrent disease, and one death meaning that disease-free survival was 96%, and overall survival was 96% (22/23) at a mean follow-up of 35.4 months. Conclusions: Transhiatal oesophagectomy for high-grade dysplasia can be performed with acceptable mortality and morbidity when performed at a specialist centre.

Key Words: Transhiatal oesophagectomy • Barrett's oesophagus • High-grade dysplasia