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This review article aims to discuss the modalities of oesophageal resection, to define the categories of patients who are most likely to benefit from oesophagectomy with extensive lymph node clearance, and to analyse the eventual contribution of nonsurgical neo-adjuvant or adjuvant therapies to improving long-term survival rates achieved by surgery alone. Both the review of the literature devoted to potentially curative treatment of oesophageal cancer and the authors' own experience indicate that resection of the oesophageal tube en bloc with the locoregional lymph nodes provides patients with the best chance of long-term survival and cure. This is true, even though some of the resected lymph nodes are metastatic. Most phase III comparative studies fail to shown any overall survival improvement following multimodal therapy in comparison with surgery alone, so that there is now no scientific reason for systematic addition of radio- and/or chemotherapy to extensive surgery in potentially resectable neoplastic processes. However, neo-adjuvant radio- and/or chemotherapy is indicated in suspected non-resectable T4 tumors for downstaging and subsequent oesophageal resection in good responders. The benefit in terms of long-term survival and cure that can be expected from adjuvant chemo- and/or radiotherapy after radical resection of a neoplastic process having already spread into a large number of loco-regional lymph node requires objective evaluation by prospective, randomized studies.

A multicenter retrospective statistical study of 2,400 patients with tumors of the esophagus and cardia was undertaken. Study of individual sites revealed the operability of certain carcinomas of the upper third of the esophagus with a reasonable five-year survival rate despite macroscopic invasion seen in more than half the patients. For the middle third of the esophagus, intrathoracic colonic esophagoplasty with esophageal resection extending as high as possible appeared to offer the best long-term results, particularly if the anastomosis was performed in the neck. Tumors of the lower third of the esophagus were also associated with better results when the esophageal anastomosis was made at a level above the aortic arch, resulting in an improved survival rate for patients undergoing intrathoracic colonic esophagoplasties. For carcinomas of the cardia, use of total gastrectomy was superior to the use of upper polar gastrectomy, but the results were better when gastric excision was also associated with esophageal excision. The finding of normal lymph nodes did not preclude recurrence of the tumor in approximately one-fourth of the patients. Esophageal sections at a distance from the tumor was not necessarily synonymous with section in a healthy area, since the sites of sections studied were either invaded (29%) or areas of neoplastic repermeation (40%). Existence of a histologically normal esophageal section site did not preclude recurrences in 27% of patients with more than one-third in the esophagus. Undifferentiated or poorly differentiated squamous cell carcinomas paradoxically appeared to have a somewhat better long-term prognosis than well differentiated forms, but the increased number of metastases associated with them confirms their unfavorable prognosis. The importance of the T/N classification was confirmed for tumors in classes T1 and T2. From Stage T3, the N criterion was not important. Incidence of postoperative mortality from fistulas appeared to decrease progressively, chiefly due to appropriate medical treatment. Cervical fistulas were associated with a mortality rate of 21%. After esophageal anastomosis above the aortic arch was performed, more than 10% of the recurrences were seen in the neck, indicating the need for extension of the incision as high as possible. Metastases to the bone were present in 15% of the patients. Preoperative radiotherapy did not lessen the number of lymph nodes found to be invaded at the time of excision; the tumors considered to be histologically "sterilized" by irradiation were nevertheless associated with a high incidence of lymph node involvement (approximately one-third) and with more than a 40% rate of distant metastases. Excisions considered to be "palliative" by the surgeon nevertheless were of definite value. The mean survival rate at five years was 12%, and one-third of these patients showed no recurrence of neoplasm.

The prospective study conducted by the Organisation internationale d'Etudes Statistiques pour les maladies de l'Oesophage (OESO) (International Organization for Statistical Studies of Esophageal Diseases) created in 1979 concerns 790 patients operated on for a tumor of the esophagus or the mouth of the esophagus. Among the preoperative investigations, endoscopic examinations were associated with a high error rate (20%). Respiratory function tests cannot constitute a formal contraindication to surgery. The value of extended surgical excision is confirmed by the results, although the need for extensive lymphatic resection has not been clearly demonstrated. The incidence of fistula has decreased, but it still remains an important element of operative deaths. However, the complications of esophagectomy are essentially pulmonary and the problem of preoperative identification of high-risk patients has not yet been resolved. The influence of various modalities of postoperative ventilation techniques were evaluated. The overall mortality rate was 14.7%, and a much broader definition of this term is required. Because of a number of contradictions in prognostic factors, the OESO group is currently testing a new clinical and histologic classification.