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Etiology and Management of Esophageal Perforation

Perforation of the esophagus is a potentially serious and life-threatening medical emergency. Given the diverse etiologies and wide variety in clinical presentations of the perforated esophagus, the managing physician must possess a thorough understanding of the principles behind its treatment, as well as have access to an array of therapeutic tools, to provide an optimal outcome. Surgical therapy has occupied a prominent place in the management…

Caustic Esophageal Injury

A caustic esophageal ingestion involves damage to the wall of the esophagus, secondary to direct contact with an acid or base, through a well-described inflammatory response. Knowledge of the pathophysiology of caustic injuries guides complex management decisions through the multiple phases of these potentially life-threatening injuries. Epidemiology There are two etiologies of caustic ingestion: accidental and intentional. The age of the patient is predictive of the…

Submucosal Tumors of the Esophagus and Gastroesophageal Junction

Submucosal tumors (SMTs) of the esophagus and gastroesophageal junction (GEJ) are a group of rare, benign lesions. This chapter will review the various types of esophageal and GEJ SMTs. We intend to focus on advancements in the imaging modalities, medical treatment, and surgical options for these tumors, including descriptions of evolving surgical techniques. Our understanding of the prevalence of esophageal SMTs comes largely from autopsy studies…

Esophageal Duplication Cyst

Esophageal duplication cyst is one of two types of foregut duplication cysts. The other type is the bronchogenic duplication cyst, and they are both classified together due to their common embryologic origin. Duplication cysts are a rare entity, with most literature consisting of case reports or small case series. It is estimated that foregut duplication cysts make up 20% of all gastrointestinal duplication cysts. Esophageal duplication…

Nonreflux Esophagitis

The esophagus has been dubbed the organ of symptoms not signs. Inflammation of this dynamic conduit will elicit manifestations that can severely impact a patient's life. These symptoms are universal regardless of the cause of inflammation. They may include dysphagia, odynophagia, heartburn (pyrosis?), chest pain, nausea, vomiting, hematemesis, anorexia, and weight loss. So-called atypical respiratory symptoms may also occur, such as cough, bronchospasm, and aspiration. Due…

Anastomotic Complications After Esophagectomy: Frequency, Prevention, and Management

Since Dobromysslow described the first esophageal resection with successful anastomotic reconstruction in 1901, the outcomes of esophagectomy have significantly improved and this surgery is now the mainstay of treatment for esophageal cancer. Data from the Society of Thoracic Surgeons (STS) National Database reported a major complication rate of 33.1% and mortality rate of 3.1%. However, anastomotic complications continue to pose a technical challenge for surgeons and…

Palliative Therapy for Esophageal Cancer

The American Cancer Society estimates that 16,940 new cases of esophageal cancer will be diagnosed in 2016, and in the same year there will be 15,690 deaths from esophageal cancer. Unfortunately, more than half of patients present with advanced disease with symptoms of dysphagia, weight loss, and less often bleeding. Palliative interventions are needed to optimize quality of life by reducing hospital admissions for aspiration and…

Options for Esophageal Replacement

Milestones in Surgery for Esophageal Carcinoma 1877—V. Czerny: first successful resection of the cervical esophagus for carcinoma 1913—F. Torek: first successful transthoracic resection of the esophagus 1913—W. Denk: cadaver and experimental animal studies on the transhiatal resection of the esophagus 1933—T. Ohsawa: first report on transthoracic esophageal resection and esophagogastrostomy 1933—G. Turner: first transhiatal resection 1938—W. Adams and D. Phemister: first single stage transthoracic resection and…

Extent of Lymphadenectomy for Esophageal Cancer

The extent of lymphadenectomy as part of an esophagectomy for cancer remains a controversial issue. The aggressive nature of the disease often means that both local nodal and distant metastases exist at the time of presentation. As such, locally advanced disease in which potential cure is intended is frequently treated with neoadjuvant modalities. The debate on degree of lymphadenectomy hinges largely on the belief that a…

Surgical Approaches to Remove the Esophagus: Robotic

The use of minimally invasive esophagectomy (MIE) has increased over the past several years. The term minimally invasive can refer to performing either or both the thoracic and abdominal phases of the operation with either laparoscopic or robotic assistance. Transhiatal esophagectomy is another form of MIE that avoids a chest incision. Recent studies have demonstrated that MIE has benefits with decreases in blood loss, chest tube…

Surgical Approaches to Remove the Esophagus: Vagal-Sparing

To date, no therapy has been proven superior to esophagectomy for the cure of patients with early-stage esophageal cancer. The primary goal of surgery is complete (R0) resection of the tumor to maximize the opportunity for cure and minimize the incidence of local recurrence. However, with early-stage disease and a high likelihood of long-term survival, there is an increasing focus on postesophagectomy quality of life, especially…

Surgical Approaches to Remove the Esophagus: Minimally Invasive

The first reports of minimally invasive esophagectomy (MIE) were published in the early 1990s by Cuschieri et al., who described a thoracoscopic esophageal mobilization in 1992, and DePaula et al., who reported an MIE with a laparoscopic transhiatal approach in 1995. The technique was popularized almost 10 years later at the University of Pittsburgh Medical Center by James Luketich, who initially adopted a modified McKeown approach with a…

Surgical Approaches to Remove the Esophagus: Open

Surgical Therapy Surgical resection remains the cornerstone of therapy for patients with resectable cancer of the esophagus in the absence of systemic metastases. Surgery, most of the time combined with neoadjuvant therapy in current practice, offers the highest likelihood of cure for patients with locoregional disease. To obtain the best results, the management of esophageal cancer should be individualized and based on a combination of factors…

Multimodality Therapy in the Management of Locally Advanced Esophageal Cancer

Esophageal cancer (EC) remains a devastating malignancy with a low rate of cure. Results in patients with early-stage disease (stage I to II) remain more promising, with long-term survival rates between 60% and 90%. Unfortunately the majority of patients present with locally advanced or advanced disease. This is associated with high rates of systemic recurrence and has demonstrated poor outcomes when treated with surgery alone. Thus…

Endoscopic Management of High-Grade Dysplasia and Superficial Esophageal Carcinoma

The detection and treatment of high-grade dysplasia and early esophageal cancer overlap to the point that they are a continuum. In some situations they can be difficult to separate and exist simultaneously. Because existing studies often combine the descriptions of the two, for the purposes of this chapter we will consider both as superficial neoplasia. Esophagectomy, long considered the only curative option for esophageal cancer, is…

Esophageal Cancer Diagnosis and Staging

Epidemiology The incidence of esophageal cancer has increased in recent decades, with an estimated 17,990 new cases in the United States in 2013. Histologically, in the United States esophageal adenocarcinoma is the fastest-growing subtype, surpassing the incidence of esophageal squamous cell carcinoma (SCC), in contrast to worldwide incidence where SCC still predominates. There is a marked variation in histologic incidence of esophageal cancer with respect to…

Epidemiology, Risk Factors, and Clinical Manifestations of Esophageal Cancer

Esophageal cancer accounts for 1% of new cancer diagnoses in the United States annually and 2.6% of cancer-related deaths. An estimated 0.5% of men and women will be diagnosed with esophageal cancer at some point during their lifetime. The two most common subtypes of primary esophageal cancer include adenocarcinoma (EAC) and squamous cell carcinoma (SCC). These differ tremendously in their natural history, epidemiologic pattern, and risk…

Ablation for Patients With Barrett or Dysplasia

Compared with the general population, patients with Barrett esophagus (BE) have a higher risk of developing esophageal adenocarcinoma (EAC) with the risk increasing in those patients who develop dysplasia—low-grade dysplasia (LGD) or high-grade dysplasia (HGD). In the past, patients with HGD or proven intramucosal adenocarcinoma (IMC) will have been considered for an esophagectomy, if they were medically suitable. This major procedure clearly removes the pathology, as…

Medical and Surgical Therapy for Gastroesophageal Reflux Disease and Barrett Esophagus

The British surgeon Norman Barrett is famously credited for his early description of the lower esophagus lined by columnar epithelium. However, he himself did not claim to be the first to describe the condition that would later bear his name. His original article in 1950 details numerous previous reports that likely represented this pathology. Throughout Barrett's impressive career, he proposed many theories that later proved to…

Epidemiology of Barrett Esophagus and Risk Factors for Progression

Prevalence and Incidence of Barrett Esophagus Barrett esophagus (BE) is the disease in which the normal squamous lining of the distal esophagus is replaced by a metaplastic columnar cell epithelium (termed intestinal metaplasia [IM]) in response to chronic severe gastroesophageal reflux disease (GERD). Its clinical importance is as the precursor lesion and major risk factor for esophageal adenocarcinoma (EAC). The epidemiology of EAC has been investigated…