Anterior versus posterior reconstruct ion after transhiatal oesophagectomy: a randomized controlled trial
In a prospective randomized trial the clinical results after transhiatal oesophagectomy with reconstruction in the anterior mediastinum (51 patients) or posterior mediastinum (45 patients) were compared. There were no diflerences in age, preoperative risk,factors, tumour stage and local (surgical) complications between the two groups. However, reconstruction in the posterior mediastinum was associated with significantly fewer days spent in the intensive therapy unit ( 9 versus 14), fewer cardiopulmonary complications ( 1 3 versus 25 per cent) and lower mortality (30-day mortality rate 2 versus 6 per cent; hospital mortality rate 4 versus 10 per cent). These data show superiority of' reconstruction in the posterior mediastinum after transhiatal oesophagectomy. This route is strongly recommended, particularly for patients with cardiopulmonary risk factors.
Transhiatal oesophagectomy has become a valid alternative to the transthoracic approach for oesophageal resection'-'. Most authors agree that the indications for transhiatal oesophagectomy are adenocarcinoma of the distal oesophagus, early squamous cell carcinoma of the distal oesophagus (Tl,2 tumours ) and benign conditions of the oesophagus that require resection such as caustic injuries6p9.
After transhiatal resection the surgeon has the choice between reconstruction in the anterior or posterior mediastinum, provided complete macroscopic and microscopic tumour excision (R, resection) has been achieved. Reconstruction in the anterior mediastinum may be considered superior because it allows postoperative irradiation of the oesophageal bed. Recently, however, improvements in patient selection and resection techniques have decreased the rate of local tumour recurrence to below 10 per cent". Furthermore, tumour recurrence was rarely found to cause obstruction of the interposed organ.
To investigate whether reconstruction in the anterior mediastinum offers any advantages over that in the posterior mediastinum, a randomized controlled trial was performed.