Two operative approaches for esophageal carcinoma were compared with respect to operative morbidity and mortality by means of multivariable analysis. From 1980 to 1986, 152 patients underwent resection by laparotomy and right-sided anterolateral thoracotomy with an intrathoracic anastomosis. From 1986 to 1989, 141 patients underwent resection by transhiatal blunt dissection with a cervical anastomosis. The stomach was the preferred organ for reconstruction. Paresis of the recurrent laryngeal nerve and leakage of the cervical anastomosis occurred significantly more often in the transhiatal group. Pulmonary complications occurred less frequently in the transhiatal group. In-hospital mortality (9% in the thoracotomy group and 5% in the transhiatal group) increased significantly with advanced age of the patients. Furthermore, it was significantly higher in case of colonic interposition as compared with reconstruction with the stomach. Long-term survival did not differ between the two groups. Especially for carcinomas in the distal part of the esophagus, transhiatal esophageal resection without thoracotomy seems to be an oncologically justifiable operation with a reduced morbidity and mortality.