Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
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Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2826 - 2829 Full Version

Transhiatal Oesophagectomy and Lymph Node Clearance in a Teaching Hospital

Published: August 1, 2010 | DOI:

(M.S), MRCSEd, Fr Muller’s Medical College, Kankanady, Mangalore, Karnataka State, India

Correspondence Address :
Dr R. Chidambaranath
Department of Surgery,
Fr Muller’s Hospital,
Kankanady, Mangalore,
Karnataka State, (India)
Ph: 00 91 824 2238297


Introduction: Transhiatal Oesophagectomy for resectable oesophageal carcinoma has been gaining popularity and acceptance as a reasonably safe procedure, given the question over the choice of procedure for these patients who are nutritionally depleted and the limitations of preoperative evaluation methods. The purpose of this study was to find the lymph node retrieval rate and to assess Transhiatal Oesophagectomy (THE) as practiced in this centre as a means of node clearance.
Methods: A retrospective audit of patients who were found fit and who underwent THE between 2004 and 2008 was done. Operative notes and histopathology reports of all patients were scrutinized. A total of 16 out of 60 patients underwent the procedure. There were no major complications in these patients and no in-hospital mortality.
Results: Out of the 16 patients who were fit to undergo THE, 8 had no nodes found on HPE, 4 had 1-3 nodes and only 2 had greater than 10 nodes which were retrieved during surgery. Post-operative complications were few and there was no in-hospital mortality.
Conclusion: The transhiatal approach may not be a reliable means of removing intratoracic nodes during Oesophagectomy for carcinoma. However, a larger study directly comparing this to a transthoracic approach in the Asian population may be necessary.


Surgery, Lymphnode, Transhiatal

Oesophageal carcinoma patients present to hospital at varying stages of disease and therefore, with varied stages of nutritional depletion. Routinely, the work up of patients with oesophageal carcinoma (OC) was with upper GI endoscopy, ultrasound scan abdomen, chest X-Ray, CT thorax, Endoscopic Ultrasound (EUS) with guided FNA, PET, Thoracoscopy and laparoscopy where available.

The two most important prognostic factors for OC are tumour depth and nodal status (1),(2),(3) with outcome, depending on the stage of the disease. The staging accuracy by modality ranged from 49-60% and 80-92% for tumour depth and 39-74% and 45-100% for nodal status by CT and EUS respectively, while MRI and PET showed 56-74% and 76-87% accuracy for nodes respectively (4).

Survival in oesophageal cancer is decided on the basis of surgical respectability and the presence of nodal disease. Current non invasive modes of staging appear far from optimal in detecting abdominal and thoracic lymph node status. The minimal invasive methods used were laparoscopy and thoracoscopy which were more useful with obstructing lesions which prevented EUS. The aim of this study was to find the extent of lymphadenectomy, both thoracic and abdominal, during conventional Transhiatal Oesophagectomy as practiced in our centre, in operable patients who were considered fit to undergo the procedure. Test of operability was a combination of nutritional status, Endoscopy, Barium swallow and CT chest and abdomen.

Material and Methods

A total of 60 patients were seen at our hospital between 2004 and 2008, with biopsy confirmed oesophageal carcinoma, of which 16 were considered fit to be operable and to undergo the procedure. Preoperative Endoscopy, pulmonary function tests and CT chest and abdomen were done to assess operability following the usual criteria. Patients with extension of the tumour outside the oesophagus (>T3), pr, Para tracheal, carinal nodes >2cm on CT, >M0 status, visceral metastasis, celiac or other abdominal nodes , neck nodes or distant metastasis were excluded from the study, as were patients who declined surgery or had medical/respiratory conditions which prevented safe elective surgery, > ASA III.

The access was through an upper midline laparotomy with sub-umbilical extension. An exploration was done to confirm operability through laparotomy. Any extension to the diaphragm and pericardium, preventing R0 resection or an extension to the stomach preventing 5cm margins on the stomach with a usable stomach remnant was looked for. All patients were planned with reconstruction with stomach. Trans Hiatal dissection was commenced with a view to look for extension outside the oesophagus, trachea, or mediastinum.

Once operability was confirmed, the stomach was mobilized by retaining the right Gastric and gastroepiploic vessels, by removing all nodes within the branches of the celiac trunk and excluding those along the splenic artery and hilum. Splenectomy was not performed in any patient. The hepatoduodenal ligament was removed with the tumour and nodes. Cervical dissection was done with an oblique left incision anterior to the sternomastoid muscle. Neck dissection was not done.
The nodes were not separately dissected from the specimen or collected from node areas separately before sending for histopathological examination. Any palpable nodes in the chest were cleared only if visualization could be achieved to ensure safe removal. All operations were performed by surgeons (3 separate teams) who routinely performed oesophagectomies for benign and malignant diseases.

The nodes were examined by pathologists who were routinely involved in seeing Carcinoma oesophagus specimens.


Out of a total of 60 patients who were diagnosed, 16 patients were found fit to undergo surgery and resection by the Transhiatal approach. 14 were males and 2 were females. The median age was 54yrs (age range -36-83yrs). 13 patients regularly had alcohol and smoked. 10 were squamous cell carcinomas, and 6 were adenocarcinomas. There were 6 mid 1/3 tumours, 4 lower 1/3 tumours and 5 of the GE junction as found on endoscopy. One patient had a growth extending from the mid to the lower third on gross pathological examination.

No nodes were found in 8(50%) patients, 1-3 nodes were found in 4(25%), 4-9 were found in 2(12.5%), and greater than 10 nodes were found in only 2(12.5%) patients.


The number of metastatic nodes is recognized as an important prognostic factor in oesophageal cancer. The UICC recommends a minimum of 6 retrieved nodes for an accurate nodal classification (5). Other than the number, the ratio of nodes was also found to have a prognostic value (6),(7).

‘THE’ has been a method of resection of OC for its advantage of fewer post operative complications and shorter hospital stay. There has been considerable number of discussions regarding whether extensive lymph node dissection should be attempted to improve staging and thus predict survival better. However, the additional value of formal mediastinal lymph node dissection remains controversial in western patients, especially with the concept that lymph node involvement may reflect systemic micrometastatic disease and that extended resections will not alter the natural history of this disease (8).Advocates of a transthoracic Oesophagectomy have suggested that the transhiatal approach limits the ability to achieve an R0 resection (9),(10),(11).

In his study, it has been found that Transhiatal surgery may not lead to a satisfactory number of nodes removed, thus limiting the ability to remove positive nodes and affecting staging and survival. The Transthoracic approach was not being very popular or being widely practiced in this institution and hence, no comparison could be made between the two. Very few studies have been found to focus on node retrieval in the Asian population via the Transhiatal approach for Oesophagectomy.


The transhiatal approach, though better in terms of lesser in-hospital mortality, morbidity and fewer long term postoperative complications, has been found to be inadequate in terms of the removal of a maximum number of abdominal or thoracic nodes. This has limited the ability to predict higher stage groups and their subsequent need for additional treatment like chemotherapy or radiotherapy following surgery, leading to similar treatment regimes being offered to these patients. More detailed and larger studies may be needed in our population to interpret the impact of Transhiatal oesophgectomy


Demeester SR. Lymph node involvement in esophageal adenocarcinoma: if you see one, have you seen them all? J Thorac Cardiovascular Surg 2003; 126(4):947-9
Vazquez-Sequeiros E, Wiersema MJ, Clain JE, Norton ID, Levy MJ, Romero Y, Salomao D, Dierkhising R, Zinsmeister AR. Impact of lymph node staging on therapy of esophageal carcinoma. Gastroenterology. 2003 Dec;125(6):1626-35.
Rice TW, Blackstone EH, Adelstein DJ, Zuccaro G Jr, et al Role of clinically determined depth of tumor invasion in the treatment of esophageal carcinoma. J Thorac Cardiovasc Surg. 2003 May;125(5):1091-102. 3
Patel AN, Preskitt JT, Kuhn JA, Hebeler RF, Wood RE, Urschel HC Jr. Surgical management of esophageal carcinoma. Proc (Bayl Univ Med Cent). 2003 Jul;16(3):280-4.
UICC: TNM Classification of malignant tumours. New York, Wiley-Liss, 2002
Roder JD, Busch R, Stein HJ, Fink U, Siewert JR. Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus. Br J Surg. 1994 Mar;81(3):410-3.
Tachibana M, Dhar DK, Kinugasa S, Kotoh T, Shibakita M, Ohno S, Masunaga R, Kubota H, Nagasue N. Esophageal cancer with distant lymph node metastasis: prognostic significance of metastatic lymph node ratio. J Clin Gastroenterol. 2000 Dec;31(4):318-22.
Andrew R Davies , Matthew J Forshaw , Aadil A Khan , Alia S Noorani , Vanash M Patel , Dirk C Strauss and Robert C Mason Transhiatal esophagectomy in a high volume institution
Omloo JM, Law SY, Launois B, Le Prisé E, Wong J, van Berge Henegouwen MI, van Lanschot JJ. Short and long-term advantages of transhiatal and transthoracic oesophageal cancer resection. Eur J Surg Oncol. 2009 Aug;35(8):793-7. Epub 2008 Nov 17.
Veeramachaneni NK, Zoole JB, Decker PA, Putnam JB Jr, Meyers BF; American College of Surgeons Oncology Group Z0060 Trial. Lymph node analysis in esophageal resection: American College of Surgeons Oncology Group Z0060 trial. Ann Thorac Surg. 2008 Aug;86(2):418-21; discussion 421.
Wolff CS, Castillo SF, Larson DR, O'Byrne MM, Fredericksen M, Deschamps C, Allen MS, Zais TG, Romero Y. Ivor Lewis approach is superior to transhiatal approach in retrieval of lymph nodes at esophagectomy Dis Esophagus. 2008;21(4):328-33.

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