Transthoracic and transhiatal esophagectomy are two common procedures for esophageal cancer resection. Prospective studies comparing the two methods in Asian people are few. In addition, the data comparing their effects on the quality of life are lacking. A prospective randomized study was conducted from January 2003. Patients of resectable esophageal cancer of comparable stage were allocated to undergo the transthoracic or transhiatal procedure in turn. They were all reconstructed with stomach interposition through the retrosternal route. Discharged patients were followed-up in the outpatient clinic. They were questioned on the topics of (i) severity of pain, (ii) ease of swallowing, (iii) satisfaction of daily activities, (iv) dependence on medications, (v) working ability, (vi) fatigue, (vii) appetite, (viii) sociality, (ix) happiness and (x) self respect, in the third, sixth and twelfth month. Also the demographic data, operative results and survival were recorded. Up to December 2006, eighty-seven patients of stage II and III, including 71 patients of middle third lesions and 16 lower third lesions were enrolled. The operation time was significantly longer, and the leakage rate was higher in the transthoracic group (Student's t-test and Fischer's exact test, respectively). However, intraoperative blood loss and postoperative hospital stay were not significantly different (Student t-test). Also, the Kaplan-Meier survival curves of these two groups were not significantly different by log-rank test (p=0.286). The score on the quality of life of transhiatal patients was significantly higher than that of transthoracic patients in the third, sixth and twelfth month. Transhiatal esophagectomy is a safe and fast procedure. The survival was similar to that of transthoracic approach. Its leakage rate was lower and quality of life was better.