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[Treatment of adenocarcinoma of the lower esophagus and cardia: resection with or without thoracotomy?].

STUDY AIM
In the treatment of adenocarcinoma of the cardia and lower oesophagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospective 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 POG through a transthoracic (n = 31) or a transhiatal approach (n = 28). All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy was only performed in patients who had a transthoracic approach. Both groups were comparable concerning age, weight and height, and tumoral staging according to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA score = 3) (NS).


RESULTS
Resection was palliative in four patients in the transthoracic group and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary complications were as frequent with and without thoracotomy (35% versus 32% respectively). 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% respectively, NS). The operative approach did not influence survival in patients 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 and lower oesophagus, the theoretical carcinologic benefit of mediastinal lymphadenectomy can be balanced with an higher operative risk related to the transthoracic approach.