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Background:The primary goal in surgery for esophago-gastric junction(EGJ) cancers is to obtain a complete resection (R0), as this is the strongest predictor of survival. The published rate of complete resection is only approx. 70% and the optimal surgical approach to achieve R0 is controversial. We sought to determine the influence of an approach tailored to patient and tumor characteristics on complete resection and post-operative outcomes.Methods: A prospectively entered database on all upper GI cancer resections at a single institution (2005-2010) was accessed for EGJ tumors (Type I, II, III). Patient demographics, operative and tumor characteristics, short term outcomes, and margin status (proximal/distal/radial) were compared between patients undergoing one of three operative approaches (Ivor-Lewis (IL): Left Thoraco-abdominal (LTA): Trans-abdominal (TA)). Operative approach was tailored to pt and tumor (EGD+CT) characteristics with a view to maximize complete resection whilst minimizing morbidity. Data presented as median (range). Mann Whitney U or Fishers Exact test determined significance (*p<0.05).Results: Of 241 pts in the database, 60 patients underwent resection of EGJ tumors (I/II/III = 12/22/26). IL was performed in 31 (EGJ I/II/III = 10/17/4), LTA in 13 (EGJ I/II/III = 1/1/11), and TA in 16 (EGJ I/II/III = 1/4/11). TA pts were older (IL 63y (24-82): LTA 62 (27-80): TA 73y (38-82))*. TA (7.2cm(1-11)) and LTA (9.8cm(4-14)) had larger tumors than IL (4.1cm(0.4-8.3))*. Post-op pulmonary complications(IL 10/31 LTA 1/13 TA 4/16), anastomotic leak (IL 4/31 LTA 1/13 TA 1/16), LOS (IL 11d: LTA 10d: TA 10d), and mortality (IL 2/31: LTA 0/13: LTA 0/16) did not differ between groups. Lymph node retrieval was higher in IL (IL 37(8-66):LTA 25(7-64): TA 25 (4-40))*, but complete resection was achieved in 57/60 (95%) and did not differ between groups.Conclusions:A tailored approach to cancers of the EGJ based on patient and tumor characteristics is feasible, is associated with a high complete resection rate, and does not increase morbidity.