Esophageal and gastroesophageal junction carcinoma: an evolved philosophy of management.

One hundred eleven patients with esophageal and gastroesophageal junction carcinoma were treated in the last 12 years. Fifty-seven (52%) underwent resection for cure (38%) or for palliation (14%). Overall operative mortality was 32% (18/57), being greatest with colon interposition (71%) or gastric tube (67%) and least with esophagogastrectomy (11%). Major complications--anastomotic leak being the most important--were strikingly more prevalent (71 and 66%) with the first two procedures than with esophgoastrectomy (14%). The mean survival time in patients resected for cure was 17 months compared to seven in those treated primarily by radiation. In addition, radiation therapy was accompanied by a 20% major complication rate and by less subjective palliation. In the surgically-resected group, there was a two, three, and five year survival of 26, 9, and 5%. Incomplete removal of tumor did not improve survival above that attained with untreated patients. Morbidity and mortality associated with use of endoprostheses in an additional 27 patients was 65%. This experience has led us to espouse the following approach: 1) The main thrust of treatment should be to resect gross tumor completely. 2) The use of the stomach in reconstruction at all levels offers the safest, most expeditious means of immediate rehabilitation. This is best accomplished by first an abdominal approach followed by a right thoracotomy, as outlined by Lewis (Br J Surg, 1946). 3) Radiation therapy should be used as post-resection adjunctive therapy or when surgery primarily is not applicable for medical reasons or refused.