Adult Chest Surgery

Chapter 37. Overview 

 

The chapters in this section are focused on benign, cystic, congenital, and traumatic lesions of the esophagus (Fig. 37-1). When compared with gastroesophageal reflux and malignant esophageal disease, benign tumors, congenital cysts, and esophageal trauma are relatively uncommon.

Figure 37-1.

 

Esophagus, anterior view.

Chapter 38 describes the most common congenital malformations of the esophagus that require surgical correction in infants and children. These include esophageal atresia, tracheoesophageal fistula, esophagotracheal cleft, hiatal hernia, vascular rings, and indications for esophageal replacement. Today, most of these entities can be corrected, and a child can lead a normal life after surgery.

Chapter 39 reviews benign tumors and cystic lesions of the esophagus. Benign tumors of the esophagus make up 1–2% of all esophageal neoplasms. However, while benign tumors and cysts account for less than 2% of all esophageal lesions, they reportedly account for up to 10% of all surgically resected esophageal lesions.Esophageal cysts include congenital and acquired lesions and are secondary either to persistent vacuoles that remain within the esophageal wall during embryologic development or to obstruction of the excretion ducts within esophageal glands. The former generally present in the early childhood years, whereas the latter present later in adult life.

Since most benign and cystic lesions are asymptomatic and do not interfere with normal esophageal function, it is no surprise that these tumors are most often discovered incidentally. In the past, most such lesions were noted at the time of other interventions. Now they are discovered more commonly on unrelated imaging studies. For lesions that do cause symptoms, the etiology typically is intraluminal obstruction or external compression secondary to a mass effect. Functionally oriented classification systems are based on location within the esophagus (i.e., intramural, submucosal, or intraluminal) and are useful clinically because they can be related to the specific presentation, diagnosis, and expected treatment. Although most of these lesions are asymptomatic, often the location within the esophageal wall is most responsible for the specific symptoms. Since benign lesions are greatly outnumbered by malignant lesions, it is advantageous to perform a comprehensive preintervention evaluation to define the nature of the lesion. In general, most benign esophageal tumors and cysts are located in the middle and lower thirds of the thoracic esophagus. Leiomyoma is the most commonly described lesion and constitutes 65% of all benign esophageal masses. Despite their benign nature, these lesions typically are resected when recognized. Surgical excision offers excellent results in terms of ease of resection, functional outcomes, and durability.

Traumatic esophageal disorders comprise several groups of injuries including iatrogenic and noniatrogenic (i.e., spontaneous blunt or penetrating and chemical or caustic) trauma. Practical approaches to managing esophageal trauma are often dictated by the nature of the underlying injury and the experience and preference of the surgeon. Consequently, although many of the same principles and techniques may apply, to ensure a comprehensive presentation of the topic, we have adhered to the accepted classification, by providing three different chapters based on etiology from the perspective of three different surgeons. Chapter 40 covers general management principles of esophageal perforation. This topic is pertinent for surgeons because esophageal perforation usually is the result of iatrogenic injury caused by instrumentation (e.g., esophagoscopy, bougienage, and achalasia dilation). Esophageal perforation can be difficult to diagnose promptly. Delay in treatment results in a high mortality rate. There are striking differences in etiology, presentation, treatment, and results of cervical versus thoracic perforation of the esophagus. Most cervical perforations respond well to simple drainage. Although the treatment of thoracic esophageal perforations is individualized, most patients are candidates for primary repair whether they are treated early or late. Chapter 41 further explores the aspects of blunt and penetrating traumatic injuries of the esophagus. In addition, this chapter discusses some of the procedure-specific complications that occur and techniques for management. Chapter 42 completes the general discussion of traumatic esophageal injuries by reviewing the arena of caustic injuries. These chemical exposures cause injuries ranging in severity from first-, second-, or third-degree burns to full-thickness necrosis and frank perforation, often requiring surgical treatment. The authors discuss the acute management of the immediate injury and follow with a review of the surgical options for chronic management or surgical replacement therapy, including treatment of common chronic sequelae from these types of chemical injuries. Finally, Chapter 43 reviews the indications for and techniques of esophageal exclusion. Despite advances in surgical technique and critical care over the past decades, esophageal perforation remains a challenging clinical problem. Early diagnosis and prompt surgical treatment are the hallmarks of successful outcome after spontaneous (e.g., Boerhaave's syndrome) and iatrogenic esophageal perforation. The most challenging issues a surgeon faces when taking care of acutely injured patients with these types of injuries is determining the proper technique for early management and deciding when to implement the appropriate therapies or interventions. This last benign esophageal chapter helps to place this clinical conundrum into perspective.

The spectrum of benign, cystic, congenital, and traumatic lesions, while uncommon, provides a diverse set of clinical situations for the operating surgeon. The advent of readily available, highly detailed imaging modalities not only has led to increased detection of lesions but also has permitted precise definition of lesions, especially important when ruling out malignancy. On one end of the spectrum are the smaller or more elective lesions. The evolution of minimally invasive techniques and endoscopic technology has permitted highly precise localization of lesions and access by means of minimally morbid surgery. These advances have permitted low-risk surgical resection of most benign lesions without compromise of safety or function. On the other end of this pathologic spectrum are the very morbid conditions or injuries that require more complex and larger surgeries. The following chapters provide a broad introduction for the surgical management of these diverse lesions and enlarge the armamentarium on which surgical practitioners may draw.

REFERENCES

1. Seremetis MG, Lyons WS, deGuzman VC, Peabody JW Jr: Leiomyomata of the esophagus: An analysis of 838 cases. Cancer 38:2166–77, 1976. [PubMed: 991129]



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