Substernal gastric bypass for palliation of esophageal carcinoma: rationale and technique.

A review of sixteen consecutive patients who underwent substernal gastric bypass (SSGB) for middle and upper thoracic esophageal cancer is presented. All patients were alcoholics and heavy smokers with significant medical risk factors. All had locally advanced, long, circumferential, obstructing lesions with regional metastases. The operative mortality rate was 36% in this group of high-risk patients with advanced disease. This high mortality rate may decrease with the modifications discussed. The previously described technique of SSGB is detailed with special reference to a modification for widening the thoracic inlet. The palliation afforded was excellent in all survivors, and the median survival time was a surprisingly long 10 months. Alternative approaches are discussed in a review of the literature. SSGB provides quite possibly the superior approach for palliative management of these difficult lesions.