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Background. Perioperative mortality and survival after esophagectomy have improved over the past 10 years. Although stage is the most powerful predictor of long-term survival, it remains unclear whether other factors influence prognosis. Methods. Between 1981-1991, 100 patients with esophageal carcinoma were uniformly treated by transhiatal esophagectomy without adjuvant therapy. Results and prognostic factors of long-term survival were analyzed by univariate and multivariate analyses (log-rank test and Cox regression model). Results. Forty-eight patients had severe associated medical conditions, and 26 patients were older than 69 years of age. Mortality was 3%, and morbidity was 68%. With a median follow-up of 52 months, median survival was 18 months. The overall 5-year survival was 23%. but it was 63% for early stages (pT1 + pT2). In the multivariate analysis, the risk of dying was increased by 4.9 (risk ratio) for patients with carcinomas invading beyond the muscularis propria (pT3 + pT4), compared to lower stages (pT1 + pT2) (P < 0.0001). To a lesser extent, long-term survival was also adversely affected by transfusions (packed erythrocytes) after controlling for stage (risk ratio 1.7; P = 0.047). Age (> 69 years), preoperative weight loss, tumor location, histology (adenocarcinoma versus squamous cell carcinoma), fresh frozen plasma, and splenectomy did not influence survival. Conclusion. In this study, transhiatal esophagectomy provided palliation for esophageal cancer with a low-perioperative mortality. Prolonged survival or cure was obtained for the majority of patients operated on in the early stages. Blood transfusions had a slight adverse effect on long-term survival.

Background. Distant metastasis in carcinoma of the esophagus and gastroesophageal junction is associated with a poor survival after resection. To improve the selection of patients for surgical and nonsurgical treatment, this study determined the influence on survival of distant metastases, as assessed on radiologic studies or proven on cytologic studies. Methods. During the period 1989-1990, 135 patients were referred to the institution in this study. On ultra-sonographic or computed tomographic studies, distant metastases were suspected in 62 patients and were absent in 73 patients. In 33 patients, metastases were proven cytologically; 32 of these patients subsequently were excluded from surgery. Twelve other patients were unfit for surgery because of their general condition. The remaining 91 patients had surgery; 77 patients had transhiatal esophagectomy, and the tumor was unresectable in 14 patients. Results. The 2-year survival rate for all patients in whom distant metastases were suspected on radiologic studies was 11.2%, and it was 44.3% for patients without metastases on these studies (P < 0.001). For patients with cytologically proven metastases, the 2-year survival rate (3%) was lower than for patients in whom distant metastases were suspected on radiologic studies but not cytologically confirmed (21.1%) (P < 0.001). There was no statistically significant difference in survival between this last group of patients and those without metastases identified by radiologic studies (P = 0.87). After resection, the 2-year survival rate decreased from 53.9% to 0% when distant metastases were present on histopathologic studies of the resected specimen (P = 0.04), and there was no significant difference in survival between patients with distant metastases suspected or absent on preoperative radiologic studies (P = 0.47). Conclusions. Surgery should be avoided in patients with cytologically proven distant metastases because the expected survival rate is low and surgery does not seem to be a life-prolonging procedure in these patients; however, patients should not be excluded from surgery on the basis of metastases identified by radiologic studies alone.

Background. Carcinoid tumors of the esophagus are rare. Most reported cases have had a poor prognosis. The authors report the case of a 64-year-old man with a 4-cm carcinoid tumor of the lower esophagus. Methods. Following endoscopic resection of an argyrophilic, nonargentaffin, carcinoid tumor of the lower esophagus, endosonography showed residual tumor, suggestive of a metastatic lymph node. The findings were confirmed at transhiatal esophagectomy. Results. No recurrence has been observed along the current 5-year follow-up. Conclusions. Lymph node metastasis does not rule out the possibility of prolonged survival in esophageal carcinoids. Endosonography is strongly advisable for preoperative evaluation.