food.37 Cases of foreign-body ingestion in adults are seen more commonly among the psychiatric

patients, patients with impaired cognition such as the elderly, and incarcerated individuals seeking

secondary gain.34–36

Endoscopy is the choice of management when nonoperative intervention is a viable option. Timing of

endoscopy is indicated by the risk of esophageal wall damage or aspiration, as well as the clinical status

of the patient. Urgent intervention using endoscopy may be required in patients with severe distress,

unable to swallow their own secretions, or with foreign bodies that are batteries or have sharp edges.

Patients who do not fit these criteria and have no evidence of severe obstruction can be handled less

urgently as most foreign objects will pass spontaneously.

Retrieval is the goal when dealing with foreign bodies that are not subjected to spontaneous passing.

General anesthesia is recommended during the entirety of this procedure. Flexible endoscopy is the

preferred method for most foreign bodies. A rigid endoscope is useful in the retrieval of foreign bodies

lodged in the proximal esophagus at the level of the cricopharyngeus muscle. Rigid esophagoscopy is a

rarer procedure and one should be familiar with the technique. Often senior surgical help should be

sought to accomplish the procedure safely and effectively because this technique is rarely used in

current training. Using either approach, the object should be reoriented with a grasper and removed

safely. When using the flexible esophagoscope, we have found the overtube to be a very useful tool for

removal of foreign bodies such that the esophagus is not injured proximally upon extrication of the

object. Esophagotomy may be required when the lodged foreign bodies are large, have sharp edges, are

embedded in the mucosa, or exceed the diameter of the rigid endoscope in all orientations. Following

removal of the foreign body, completion esophagoscopy and contrast esophagoscopy should be

performed to rule out injury. If there is a perforation, it should be managed according to the algorithm

in Algorithm 43-1.

BENIGN NEOPLASMS

Table 43-3 represents a list of all benign neoplasms of the esophagus. All of these lesions are rare, with

leiomyoma making up roughly 60% to 70% of all cases.38,39 Esophageal polyps are also seen frequently

in large referral centers and will be discussed. Other listed benign neoplasms of the esophagus will not

be discussed in this chapter, but the possibility of an occurrence should be noted, especially during the

formulation of a differential diagnosis.

Leiomyoma

As mentioned above, leiomyomas are by far the most common benign neoplasms of the esophagus,

accounting for roughly 60% to 70% of these cases.38,39 The incidence of leiomyoma of the esophagus

reported in autopsy range from 0.005% to 5.1%.40 Histologically, approximately 80% of leiomyoma

originates from the muscularis propria and are located intramurally. Upon visual inspection of the

esophagus, they are typically located in the middle and lower esophagus. They have been reported to

present as single lesions. Because leiomyomas are slow-growing tumors, the size of these lesions often

do not change for many years. Over 50% of these patients often are asymptomatic due to the nature of

the growth.39

CLASSIFICATION

Table 43-3 Classification of Benign Esophageal Tumors

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Algorithm 43-3 depicts the process for evaluating and treating esophageal leiomyomas. Evaluation of

a patient suspected of having a leiomyoma should begin with a barium swallow, endoscopy, EUS, and

CT scan of the chest. Figure 43-4 depicts the typical appearance of an esophageal leiomyoma located in

the midthoracic of the esophagus. This smooth walled characteristic may indicate that mucosa is not

involved and that the lesion is contained in the submucosal layer. Figure 43-5 offers the endoscopic

appearance of a distal esophageal leiomyoma. The utility of the EUS also gives clinicians the ability to

ascertain the layer of origin of the mass. EUS in combination with fine-needle aspiration (FNA) may be

used to obtain tissue for histologic studies such as immunohistochemical (IHC) analysis. IHC analysis is

helpful in differentiating leiomyomas from other more aggressive pathology such as leiomyosarcomas

and gastrointestinal stromal tumors (GISTs) and should be incorporated into the surgical planning for

diagnosis.41 However, FNA should not be routinely performed due to the association between

preoperative biopsy and mucosal perforation at the time of surgical enucleation.42

Treatment in asymptomatic patients with tumors <3 cm is currently controversial. Nonoperative

surveillance or resection should be discussed with patients in this cohort. The surgical removal of an

esophageal leiomyoma is indicated with the development of symptoms of dysphagia, an increase in

tumor size, mucosal ulcerations, and to definitively rule out a malignant process such as a

leiomyosarcoma.

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Figure 43-4. Esophagram of a leiomyoma. The acute angle at its junction with the esophageal wall is typical. (Reproduced with

permission from Orringer MB. Tumors of the esophagus. In: Sabiston DC Jr, ed. Textbook of Surgery. 13th ed. Philadelphia, PA: WB

Saunders; 1986:736.)

Figure 43-5. Endoscopic appearance of an esophageal leiomyoma at the level of the gastroesophageal junction. (Courtesy of

Michael L. Kochman, MD, Hospital of the University of Pennsylvania, Philadelphia.)

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Algorithm 43-3. Evaluation and treatment of esophageal leiomyoma.

Like other lesions of the esophagus, the surgical approach is dependent on tumor location, size, and

characteristics. The typical approach to leiomyomas originating from the mid to distal esophagus is via

the right thorax. Surgical extramucosal enucleation is an approach that has shown excellent results with

patients with leiomyomas that are less than 8 cm without annular characteristics. Mortality was found

to be less than 1% for this approach with over 90% of patients symptom free at 5 years.43

Minimally, invasive approaches to enucleation have also been shown to be effective, particularly in

tumors smaller than 5 cm. Zaninotto and colleagues performed 11 video-assisted enucleations of

leiomyomas of the esophagus with no major morbidities, including death or postoperative leaks.44

Leiomyomas greater than 8 cm or annular in character usually require esophageal resection. Approaches

and techniques to esophageal resection will be covered later in this chapter.

Fibrolipomas and Fibrovascular Polyps

Fibrolipomas and fibrovascular polyps are rare tumors of the esophagus that often present as an

intraluminal mass originating from the cervical portion of the esophagus. Clinically, these tumors will

decrease intraluminal diameter and volume, and patients will present with dysphagia. The growth of

these tumors are influenced by the peristaltic action of the esophagus, causing these lesions to elongate

over time.45 The stalk-like nature of esophageal fibrolipomas can be seen endoscopically and

subsequently should be removed. Cervical esophagotomy or right thoracotomy approaches may be

required for resection if the size of the lesions restrict mobility. In rare instances, patients can present

with their polyp protruding from their mouth after an episode of coughing or emesis (Fig. 43-6). Polyps

may also flip and cause blockage of the airways and should be excised to avoid this occurrence.

MALIGNANT NEOPLASMS

Tumors of the esophagus include adenocarcinoma, squamous cell carcinoma, small cell carcinoma,

leiomyosarcoma, rhabdomyosarcoma, fibrosarcoma, liposarcoma, lymphomas, and metastatic lesions

from the other sites. Adenocarcinoma and squamous cell carcinoma are the most common, with

adenocarcinoma emerging in recent years in epidemic type rates of increase (Fig. 43-7). Recent analysis

of incidence has demonstrated that there are about 17,000 cases diagnosed each year in the United

States. About 14,000 will die annually. The lifetime risk of developing esophageal cancer is 0.5%, with

a slightly higher incidence in males. Risk factors include tobacco, alcohol, and obesity. Tylosis is the

only recognized family syndrome that predisposes patients to the development of esophageal cancer. It

is an autosomal dominant disorder that has been mapped to chromosome 17q25.40 These patients have a

95% risk of developing squamous cell carcinoma of the esophagus by age 70.

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Figure 43-6. This patient presented with a large esophageal polyp protruding from her mouth following an episode of coughing.

This polyp was found to originate from a narrow stalk in her cervical esophagus and was removed endoscopically. Of note, she

had undergone operative resection of a cervical esophageal polyp earlier in life.

Figure 43-7. Relative change in incidence of esophageal adenocar-cinoma and other malignancies (1975–2001). Data from the

National Cancer Institute’s Surveillance, Epidemiology, and End Results program with age-adjustment using the 2000 U.S. standard

population. Baseline was the average incidence between 1973 and 1975. Blue line, esophageal adenocarcinoma; green line,

melanoma; orange line, prostate cancer; yellow line, breast cancer; purple line, lung cancer; red line, colorectal cancer. (Adapted with

permission from Pohl H, Welch G. The role of overdiagnosis and reclassification in the marked increase of esophageal

adenocarcinoma incidence. J Natl Cancer Inst 2005;97:142–146.)

Diagnosis and Staging

The vast majority of cases of esophageal cancer present late. The disease is largely asymptomatic due to

the location of the tumor and clinical symptoms do not drive patient presentation until there is a

significant degree of obstruction or bleeding. As a muscular conduit, the esophagus is quite

accommodating until it is narrowed significantly. Up to 80% of patients present with dysphagia and

20% present with odynophagia. More subtle signs of a problem are often elicited retrospectively when

questioning patients, where they admit to retrosternal discomfort and progressive symptoms that have

been overlooked. When one investigates further, it is often discovered that the patient has altered their

lifestyle or eating habits for a period of time. Typically patients have had difficulty with solids and then

liquids as the tumor progresses. The vast majority of patients have significant weight loss on

presentation and weight loss of more than 10% is a significant predictor of poor prognosis.46

Patients may also present with significant pulmonary symptoms when there is a more advanced

process leading to aspiration or there is direct airway invasion by a tumor. Direct airway invasion can

occur with midesophageal tumors as the esophagus courses directly posterior to the left mainstem

bronchus. New hoarseness is indicative of locally advanced tumor due to vocal cord paralysis. The

Virchow node, a palpable left supraclavicular node, may be present in some patients. These findings are

all indicators of poor prognosis and advanced disease.

The evaluation of a patient with suspected esophageal cancer involves a number of different tests

which are aimed at accurate diagnosis and staging. This is extremely important as therapy decisions are

made based on both of these findings. Barium swallow and esophagram are the mainstays of diagnosis

for assessment of patients. Barium swallow obtains both anatomic and functional information. Flexible

esophagoscopy is used to precisely locate the tumor, and biopsy can be performed to determine

histology. In patients with a known tumor, important additional information can be obtained by EUS

and this is considered the single most important test for determining T stage of the tumor. EUS

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