Surgical treatment of adenocarcinoma of the cardia and lower oesophagus: resection with or without thoracotomy?

Study aim: In the treatment of adenocarcinoma of the cardia and lower oesop hagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospe ctive study was to compare mortality, morbidity and long-term survival in a series of patients operated on with or without thoracotomy, Patients and method: From January 1991 to June 1997, 59 patients (mean ages : 65 +/- 10 years, range: 30-83) underwent FOG through a transthoracic (n = 31) or a transhiatal approach (n=28), All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy w as only performed in patients who had a transthoracic approach, Both groups were comparable concerning age, weight and height, and tumoral staging acc ording to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA scor e = 3) (NS). Results: Resection was palliative in four patients in the transthoracic gro up and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary co mplications were as frequent with and without thoracotomy (35% versus 32% r espectively). Global (curative and palliative resections) 3-year actuarial survival was similar in both groups (transthoracic: 39% versus transhiatal: 46%, NS), as well as survival after curative resection (44% versus 49% res pectively, NS). The operative approach did not influence survival in patien ts N+ (22% versus 17% respectively, NS) and in patients N- (86% versus 77% respectively, NS). Conclusion: These results suggest that, for adenocarcinoma of the cardia an d lower oesophagus, the theorical carcinologic benefit of mediastinal lymph adenectomy can be balanced with an higher operative risk related to the tra nsthoracic approach. (C) 2000 Editions scientifiques et medicales Elsevier SAS.