For patients proceeding to surgery with the expectation of resection but who are found to be unresectable due to metastasis or locally advanced disease, a number of options are available. Some authors advocate palliative resection with transhiatal esophogectomy whenever possible. Others argue that whatever the morbidity, resection is hardly justified for a disease with such poor life expectancy at its advanced stages. The potential for endoscopic dilation, laser or radiofrequency ablation with dilation and stenting, and radiation with or without chemotherapy in the patient found to be unresectable are recognized options. The choice is usually determined by institutional capability, as there is no evidence favoring one treatment over another in terms of overall improved survival.
For patients presenting as stage IV, radiation and chemotherapy offer the best hope for palliation. Photodynamic therapy and various permutations of stenting via endoscopy are attractive for patients without the option of combined chemoradiation therapy.
Palliative bypass, previously often alluded to, has all but disappeared. The only surgical therapy with appeal in this circumstance is transhiatal esophagectomy for patients with near complete esophageal obstruction, good performance status and a resectable primary with limited metastatic disease.
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