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BACKGROUND: The relationship between mortality and volume of esophageal resections is becoming increasingly clear. Many surgeons advocate that a single technical approach is routinely more successful. We contend that adapting the surgical approach according to individual patient and tumor characteristics will improve outcomes.
METHODS: All patients undergoing esophageal resection over a 13-year interval were prospectively followed in an IRB approved database. Surgical approach was modified according to tumor type and location as well as patient body habitus, previous surgery, and comorbidities.
RESULTS: Between May 1991 and July 2004 301 consecutive patients, mean age 62.9 years underwent esophageal resection. Surgery was required for malignant disease in 267 (Stage II and III 63%) and benign disease 34. Patients demonstrated ASA Levels III and IV in 60%. Surgical approach involved left thoraco-abdominal 196, Ivor Lewis 71, transhiatal 26, three stage 5, retrosternal 3. Mean operative length was 487 minutes (range 108-746). Mean operative blood loss 239cc (range 50-2000). Only 17 patients (6%) required intra- or post-operative blood transfusions. Mean ICU stay 2.3 days (range 1-30). Mean hospital stay 11.6 days (range 6-49). All patients had patient controlled epidural anesthesia and 300 (99.7%) were extubated in the operating room. Major or minor complications occurred in 153 patients (50.8%). In hospital and 30-day mortality was 1 patient (0.3%).
CONCLUSIONS: The best results with respect to esophageal resection will not only be associated with centers with high volumes, but also with surgeons who apply a diversified surgical approach.