Cancer of the oesophagus and gastric cardia: standard oesophagectomy and anastomotic technique

We reviewed the operative results of 785 one-stage resections for carcinoma of the oesophagus and cardia, out of a total of 1,264 patients with this tumour managed over a 12-year period (62%). Resection was considered curative in 321 patients (41%), and was palliative in 464 patients (59%). Seventy percent of patients had operative Stage III disease, while 5% had Stage IV disease. The two most frequently performed procedures were the transthoracic Lewis-Tanner operation (49%), and the transhiatal oesophagectomy (14%). Our results showed comparable operative morbidity, mortality and survival between the two resection groups, with the exception of a higher risk of recurrent nerve injury after the transhiatal operation (18% versus 9%). The results were based on selection criteria favouring patients with increased pulmonary risks for the transhiatal approach, while patients with advanced middle-third tumour were selected for the transthoracic approach. The overall leakage rate was 4%, and was the same for anastomosis made by the hand-sewn method, using a single layer continuous absorbable monofilament suture, and anastomosis made with circular stapler. The leakage rate was the same irrespective of whether the anastomosis was made in the neck or in the chest. However, stapled anastomosis has the disadvantage of a higher risk of fibrotic stricture formation. The 30-day and hospital mortality for the 785 patients was 5% and 14%, respectively. An improvement in the hospital mortality was observed over the 12-year period, with a 16% incidence for the first six years, and 11% for the subsequent six years (P = 0.03). The five-year survival after curative and palliative resection was 35% and 6%, respectively, and was 18% overall