Surgery and current management for cancer of the esophagus and cardia.

The current status of carcinoma of the esophagus is reviewed, with specific discussions on current problems. These are difficulties in staging the disease, confusion in the classification, surgery vs. radiation therapy, palliative vs. curative resection, transthoracic vs. transhiatal resection for palliation, and stomach vs. colon as an esophageal substitute after resection. The importance of dysphagia as the presenting complaint is stressed, and the etiologic factors for squamous and adenocarcinoma are reviewed, with a focus on Barrett's esophagus. In management, an emphasis is placed on intraoperative staging, the selection of patients for curative resection, the theory and use of en bloc resection, and the effect of tumor localization on the choice of surgical procedure. A description of the operative technique for cervical lesions, and transthoracic, transhiatal, and en bloc resection of thoracic lesions is given. The palliative benefit of bougienage, intubation, surgical bypass, radiotherapy, laser therapy, and electrical coagulation is summarized. The benefits of intubation are stressed. The recent advent of combination therapy, particularly with regard to chemotherapy and surgery, is discussed. Although such therapy is exciting in isolated patients, the results are not sufficiently predictable to be considered as standard therapy. More work needs to be done to identify those patients most apt to benefit from the variety of therapeutic modalities available.