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Current Application

Brian P. Whooley, MD; Simon Law, MBBChir,FRCS(Edin); Sudish C. Murthy, MD,PhD; Andreas Alexandrou, MD; Kent-Man Chu, FRCS(Edin); John Wong, PhD,FRACS

Arch Surg. 2002;137:1228-1232.

Hypothesis  With the introduction of safe, effective nonoperative alternatives, bypass surgery for unresectable esophageal cancer is infrequently performed, but it has a limited role in palliation of esophageal cancer that needs to be defined.

Design  Retrospective cohort study.

Setting  Department of Surgery at Queen Mary Hospital in Hong Kong.

Patients  Patients who had unresectable esophageal cancer and underwent bypass surgery between January 1, 1991, and December 31, 1998.

Intervention  Bypass procedures were performed using a gastric or colonic conduit to the neck.

Main Outcome Measures  Morbidity and mortality and quality of palliation.

Results  Thirty-eight patients underwent retrosternal bypass to the neck using a gastric (n = 27) or colonic (n = 11) conduit. Ten patients (26%) underwent unplanned bypass at the time of exploration for resection because of unexpected findings of T4 disease (n = 2) or technical difficulties in addition to advanced disease (n = 8). Between 1991 and 1994, 1 of 26 bypasses was unplanned and the hospital mortality was 42% (11/26), while between 1995 and 1998, 9 of 12 bypasses were unplanned and the hospital mortality was 8% (1/12). There were 12 hospital deaths in the planned bypass group (n = 28) and none in the unplanned bypass (n = 10) group (43% vs 0%, P = .01). The median survival in patients who underwent unplanned bypass was 6.9 months, compared with 1.9 months in patients who underwent planned bypass (P = .004). All patients were discharged from the hospital on at least a semisolid diet.

Conclusions  The Kirschner operation is largely obsolete as a planned procedure because of high morbidity and mortality. Bypass surgery, however, is a reasonable option as an unplanned procedure when resection is precluded at the time of exploration because of unexpected adverse operative findings.

From the Department of Surgery, Bon Secours Hospital, Cork, Ireland (Dr Whooley); and Division of Esophageal Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong (Drs Law, Murthy, Alexandrou, Chu, and Wong).