During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. You would recommend

Esophagogastrectomy celiotomy ......... Perforation of the esophagus in the chest is a surgical catastrophe that requires aggressive intervention in viually all circumstances. While that intervention can usually consist of effos to patch the perforation and drain the mediastinum concomitant obstructive esophageal disease, whether inflammatory stenosis or cancer, mandates removal or bypass of the obstruction if control of the leak and its consequent persisting mediastinal and pleural contamination is to be accomplished. For distal esophageal cancers, many thoracic surgeons would use the classic Ivor-Lewis operation, which consists of mobilizing the stomach in the abdomen and then performing a right thoracotomy with mediastinal clean out, esophagectomy, and esophagogastrostomy. In some circumstances, and by some surgeons' preference, a left thoracotomy approach might be used. The transhiatal approach would probably be avoided in this situation where an unknown amount of mediastinal contamination has taken place.