Surgery for carcinoma of the oesophagus.

Carcinoma of the oesophagus is a relatively uncommon malignancy in the United Kingdom, with a mean incidence of approximately 7.5 per 100,000 population. However, this translates into some 4,000 deaths per annum, and management of oesophageal cancer presents a major therapeutic challenge. The reasons for this are the magnitude of surgery involved in resection of oesophageal tumours, and the poor general condition and nutritional status of patients at the time of presentation. As a consequence of these factors, the potential for morbidity and mortality following resectional surgery is high. Dysphagia is the commonest presentation of oesophageal cancer in the Western World, and by the time this symptom is manifest, some two-thirds of the circumference of the oesophagus is involved by tumour.' It is hardly surprising therefore that even in those tumours considered resectable, over 90% have penetrated the full thickness of the oesophageal wall and 72% have metastasized to lymph nodes.2 In these circumstances, it is hardly surprising that resectability rates as high as 30% have been reported, in those patients initially considered suitable for surgery.3 This review article by Earlam and Cunha-Melo did little to enhance the reputation of surgical treatment of oesophageal carcinoma by also reporting an overall operative mortality of 29% and five year survival of 4%. The clinician's dilemma of how to best manage these unfortunate patients was compounded by the increasing availability of palliative modalities such as endoscopic intubation and laser therapy at the time of publication of this rather depressing review. This review has, however, been criticized on the grounds of being historical and retrospective, and unrepresentative of the current level of achievement in specialist units. Indeed, more recent reports from such units are more optimistic, with operative mortality around 10% or less and five year survival between 10 and 20%.48 The principal reasons for improved outcome in such circumstances include better staging techniques, enabling more appropriate patient selection, and a greater understanding of' factors influencing morbidity and mortality in relation to pre-operative preparation, operative and anaesthetic technique and postoperative management.