The Kirschner operation in unresectable esophageal cancer: current application

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.