SURGICAL RETROSPECTION The Origins of an Operation: A Brief History of Transhiatal Esophagectomy Attila Dubecz, MD,* Levente Kun, MD,† Rudolf J. Stadlhuber, MD,‡ Jeffrey H. Peters, MD,* and Seymour I. Schwartz, MD* Surgeons are not justified at present in undertaking resection of the thoracic portion of the esophagus when it is the site of carcinoma - the more so because they cannot perform an adequately radical operation since the diagnosis is seldom or never made early enough for it to do any good.” —Handbuch der praktischen Chirurgie, 1899 There are operations which should not be tried, even on the animal, because failure is certain, and because they can never be applied to the human subject” —Potemski, 1895 D espite its 100 year history, esophagectomy remains one of the most challenging procedures of the 21 st century. It can be, and is, performed through right or left thoracotomy, laparotomy or combinations of these, and as of the 1990s has been approached via minimally invasive techniques. The rather unique and unusual “blunt” transhiatal esophagectomy has become among the most common means of esophageal resection. Herein we review the origins of this unusual and interesting surgical undertaking. In 1978, Marc Orringer ushered in the modern era of trans- hiatal esophagectomy with the presentation of the paper, “Esopha- gectomy without Thoracotomy,” The ensuing discussion provided many references to the early history of esophageal surgery. Ronald Belsey indicated that he was very interested in this “essay on blind surgery and Orringer’s expedition into the dark Ages.” Others recalled their memories of surgical history by referring to long- forgotten pioneers of transmediastinal esophagectomy without tho- racotomy. Orringers paper credited Wolfgang Denk, an Austrian surgeon with primacy in the performance of the procedure in both cadavers and animals. 1 But Denk’s 1913 publication cites a prior report by Alwin Ach, describing his experiments with transhiatal esophageal resection in animal and procedures on 3 patients while he was working in Munich. 2 Alwin von Ach (1875—1924) The first description of esophagectomy without thoracotomy was published in 1913 by Alwin von Ach working in Munich. 2 The procedure was unsuccessful and coincidentally was performed the same year as Torek’s first transthoracic esophagectomy. 3 It appeared as the dissertation (Fig. 1) of Ach, a young German surgeon, 3 who worked under the tutelage of Professor Ottmar von Angerer (Fig. 2). Ach later followed Angerer as the interim leader of the department, just prior to the 1918 appointment of Ernst Ferdinand Sauerbruch to the chair of the Ludwig Maximilians University in Munich. This ground-breaking work was presented in 2 parts. In the first, Ach reviewed reports of previous attempts and methods used in the surgical treatment of benign and malignant diseases of thoracic esophagus. He outlined the different methods of thoracotomy, anas- tomosis, and restoration of gastro-intestinal continuity as proposed by Sauerbruch, Roux, Kuttner, and others. In the second part, he described his own experiments initiated after a fatal attempt of esophageal resection in a patient with esophageal cancer. Based on his experience in dogs, where he tried and failed with every described method of intrathoracic esophageal resection, Ach came to the conclusion that the 2 main reasons for the adverse results were respiratory failure due to the thoracotomy and mediastinitis associ- ated with leakage of the esophageal anastomosis. Influenced by the 1898 publication of the work of fellow German surgeon William Levy in the Langenbeck’s Archiv fur Chirurgie, 4 Ach began to conduct his experiments. Levy had transected the esophagus of dogs in the neck, passed a suture down the lumen of the thoracic esophagus exiting through a previously constructed gastrostomy, and then pulled the suture from the abdo- men thus removing the entire thoracic esophagus through the gas- trostomy (Fig. 3). Although not intended as such, this represents the first experimental vagal sparing esophagectomy and trasmediastinal esophagectomy in dogs. Ach’s Operation Following the completion of a series of 54 experiments in dogs, Ach operated on a 55-year-old patient who presented with dysphagia and weight-loss and was diagnosed with an ulcerated esophageal cancer on esophagoscopy. The operation took place on June 07, 1912. A Roth-Draager apparatus maintained narcosis. A left subcostal incision and exploration of the abdomen revealed an extensive cancer at the gastro-esophageal junction (Fig. 6). He next mobilized the cervical esophagus, and placed the patient in a Brauer positive pressure chamber (Fig. 4). Continuing with the laparotomy, the hiatus was both sharply and bluntly dissected. Both pleural cavities were opened inadvertently. The esophagus was then transected and ligated above the tumor. The ligature of the distal stump of the esophagus was fixed to a steel rod introduced orally by the surgeon administering anesthesia. The esophagus was removed through the neck as the operating surgeon dissected the cervical portion (Fig. 5). A cervical esophagostomy was created through a separate incision in the subclavicular region. Through the abdominal incision, the distal esophagus containing carcinoma and the proxi- mal stomach were removed (Fig. 6), and a Witzel-gastrostomy constructed into which a rubber tube was placed. The operation lasted 1 hour and 25 minutes. Gastrostomy feeding was started on the first postoperative although the patient died on the 17 th postop- erative day, likely secondary to malnutrition. Ach repeated the operation on 2 more patients in 1912 and 1913. Both patients succumbed to pneumonia on the 4th postoperative day. 5 Wolfgang Denk (1882–1970) Wolfgang Denk, an Austrian surgeon (Fig. 7) whose life included a (failed) run for the Austrian Presidency in 1957, pub- lished his experiments in both animals and cadavers with carcinoma of the thoracic esophagus in 1913. 2 Resection was approached using a modified Mayo-vein stripper (Fig. 8A) on the healthy portion of From the *University of Rochester, School of Medicine and Dentistry, Depart- ment of Surgery, New York; †Semmelweis University, Faculty of Medicine, Department of Family Medicine, Budapest; and ‡Creighton University, School of Medicine, Department of Surgery, Nebraska. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0003-4932/09/24903-0535 DOI: 10.1097/01.sla.0000345936.63500.aa Annals of Surgery • Volume 249, Number 3, March 2009 535