Surgical possibilities of oesophageal cancer

The number of options now open to surgeons in the treatment of carcinoma of the oesophagus is considerable. One, two or three different approaches can be used to remove tumours at any level between the hypopharynx and the cardia. The Sweet procedure involves a left thoracotomy followed by anastomosis. The Lewis Tanner operation begins with the stomach being mobilized through an abdominal approach followed by resection and anastomosis by a right thoracotomy. A triple approach--cervical, thoracic and abdominal--is selected when anastomoses are extrathoracic. In McKeown's operation, the whole stomach is used and the posterior mediastinal route selected. Akiyama tubulizes the stomach and has chosen the retrosternal route. Orringer has recently developed oesophagectomy without thoracotomy. When tumour removal is impossible or there is a local or general reason for refusing excision, the surgeon can turn to palliative surgery to give the patient the means of enjoying a normal life during the time that is left to him. The whole stomach can be used or it can be made into a tube by resecting the lesser curvature. Postlethwait made use of Lortat-Jacob's technique. Reversing the stomach has also been suggested. Colonic oesophagoplasty is possible if previous gastrectomy has been carried out. The surgical management of malignant oesophagotracheal fistulae can be limited to bipolar exclusion of the oesophagus. Ideally, a retrosternal gastric plasty should also be performed with drainage of the lower oesophagus into a Roux-en-Y loop. The choice of treatment is made on the basis of the preoperative assessment of the patient. The extent of disease spread is evaluated. The most important diagnostic tools are fibreoptic bronchoscopy and ultrasound. The type of surgery selected is contingent on the tumour site and the patient's physical condition. Oesophagectomy without thoracotomy has meant that surgery is available to patients for whom thoracotomy would have been inadvisable. Malignant oesophagotracheal fistulation must be treated by the Kirschner operation. Palliative bypass is carried out only in patients under 50 years of age. It is our opinion that surgery is too often overlooked in the treatment of oesophageal carcinoma. The survival rate at 5 years is 23% for potentially curable resection and the operative mortality 2.6%. In other cases, palliative resection (or bypass for patients under 50) allows the patient to feed himself and lead a normal life until the inevitable fatal outcome.