objective follow-up reveals high recurrence rate. J Am Coll Surg 2000;190:553–560.

215. Salminen PT, Hiekkanen HI, Rantala AP, et al. Comparison of long-term outcome of laparoscopic

and conventional Nissen fundoplication: a prospective randomized study with an 11-year follow-up.

Ann Surg 2007;246:201–206.

216. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after

laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg

2006;244:481–490.

217. Rosen R, Nurko S, Furuta GT. Impeding gastroesophageal refluxate: a new application of an old

medication. Gastroenterology 2003;125:984–985.

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Chapter 43

Esophageal Tumors and Injury

Jonathan D’Cunha and James D. Luketich

Key Points

1 The esophagus lacks a serosal layer. This is distinctive from other parts of the gastrointestinal tract.

It is a major factor as tumor growth radially is not limited as in other gastrointestinal cancers.

2 Esophageal perforation is a morbid clinical entity that has increasing incidence due to invasive

procedures where iatrogenic injury accounts for over 50% of cases.

3 The management of esophageal perforation is dictated by location of the perforation, the clinical

condition of the patient, and the presence of underlying pathology.

4 Esophageal stenting is a newer modality which has a role in esophageal perforation in well-selected

clinical cases.

5 The incidence of esophageal adenocarcinoma mirrors the rise in gastroesophageal reflux disease and

obesity at an epidemic rate.

6 In advanced stages, neoadjuvant therapy for esophageal adenocarcinoma suggests a survival

advantage when chemoradiation is given prior to surgery for advanced disease. Early stage disease

with minimal to no nodal involvement may go directly to surgery in selected cases.

7 Surgery remains the primary therapy for esophageal cancer and options include transhiatal

esophagectomy, Ivor Lewis esophagectomy, three-field esophagectomy, thoracoabdominal

esophagectomy, and minimally invasive esophagectomy.

8 Minimally invasive esophagectomy can be performed safely with excellent oncologic outcomes and

lower morbidity than the open procedure.

9 There are numerous palliative options for the patient with advanced esophageal cancer to maintain

comfort, afford oral intake, and manage the symptoms of the disease in the end-stage situation.

INTRODUCTION

The esophagus is an active conduit that assists in transfer of food and secretions from the pharynx to the

stomach. The esophagus is an organ of motility and provides no absorptive function. It also isolates the

food and secretions from the mediastinum during transit.

Although the esophageal anatomy has been reviewed in the previous chapter, there are several points

of consideration which need to be outlined as they are particularly relevant to surgical practice. First,

three indentations can be identified on esophagram (Fig. 43-1). The cricopharyngeus muscle is the most

proximal indentation and is a common location for iatrogenic perforation. The second indentation is the

aortic arch which is just to the left of the esophagus and a common location for foreign body or food

impaction. The third indentation is the left mainstem bronchus.

In the adult, the length of the esophagus is somewhat variable and certainly becomes relevant in the

presence of a perforation, injury, or any requirement for reconstruction. The average overall length of

the esophagus is 24 cm, with the esophagus beginning at the cricopharyngeus which is 14 to 16 cm from

the incisors in an average-sized adult and ends at the gastroesophageal sphincter which is located 38 to

40 cm from the incisors when measured endoscopically.

The blood supply to the esophagus is segmental. The esophagus is vascularized by numerous arteries

coursing through the lateral attachments and has an extensive submucosal collateral circulation. The

cervical esophagus receives blood from the superior and inferior thyroid arteries. Multiple

aortoesophageal arteries supply the intrathoracic esophagus and connect via collaterals with the inferior

thyroid, intercostal, bronchial, inferior phrenic, and left gastric arteries. This blood supply is especially

relevant during any operation on the esophagus and control of these segmental vessels is critical for a

smooth operative and postoperative course.

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1 The esophagus is composed of an outer longitudinal muscle layer and an inner layer of circular

muscle. There is no serosal layer and this is a critical consideration when one thinks about disease

processes of the esophagus. The lack of serosal layer is a distinguishing feature of the esophagus when

compared with other parts of the gastrointestinal tract. The esophagus also has a unique submucosal

layer which has a high fat content. This leads to an overlying mobility of the mucosa and propensity for

proximal retraction such that care must be taken when placing sutures for reconstruction and

minimizing the potential for anastomotic leak. The intramural lymphatic network is predominantly

located within the submucosa of the organ. This is a rich lymphatic network which is especially relevant

when one considers oncologic spread of tumor. There are also lymphatic channels within the lamina

propria of the mucosa. All of this sets the stage for even superficial tumors to be associated with nodal

metastases.

The esophagus is innervated by the autonomic nervous system. The cervical esophagus receives

parasympathetic innervation through the recurrent laryngeal branches of the vagus nerve. Thus, injury

to the recurrent laryngeal nerve not only produces vocal cord dysfunction, but also upper esophageal

sphincter dysfunction.

ESOPHAGEAL INJURY

Perforation

Esophageal perforations are a major source of morbidity (10% to 60%) and mortality (4% to 50%);

furthermore, following a perforation, 10% to 50% of patients develop strictures requiring dilations.1–9

To date, no unified approach is available to treat these complex problems. Accurate diagnosis and early

treatment are essential to the successful management of these complicated and often significantly ill

patients. Some investigators suggest aggressive operative intervention (e.g., surgical exploration and

repair or gastric conduit takedown with diversion) for patients with postesophagectomy intrathoracic

anastomotic leak, while others recommend nonoperative management with stenting, jejunostomy feeds,

perianastomotic drainage, and broad-spectrum antibiotics.5,10–15 Guidelines for either approach may

work depending on the injury and thoracic surgeons must incorporate clinical judgment in the

therapeutic decision-making process. The decision is influenced by the location and size of the

perforation, the timing and mechanism, the degree of periesophageal soling and extravasation,

coexisting pathology of the esophagus, the patient’s overall clinical condition and perhaps most

importantly, the experience of the surgeon.

Figure 43-1. Barium contrast esophagography showing the constriction caused by the cricopharyngeal muscle, aortic arch, and the

left mainstem bronchus. Indentations of the esophagus made by external structures are important anatomic landmarks and are

often the sites of perforation due to instrumentation.

2 The incidence of perforation has risen in the modern era due to the rise in endoscopic interventions.

The causes of esophageal perforation are listed in Table 43-1. Generally speaking the incidence of

iatrogenic perforation (59%) far outweighs the incidence of spontaneous perforations (15%).12 Other

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less common injuries include foreign-body ingestion (12%) and trauma (9%). Ingestion of foreign

bodies or caustic materials most commonly causes perforations in the anatomic areas just proximal or at

narrowing (cricopharyngeus, level of aortic arch, and the level of left mainstem bronchus). Also

included in the area at risk is the lower esophageal sphincter zone. External penetrating trauma can

occur at any level but is seen more commonly in the cervical esophagus as the mediastinal portion is

posterior and protected by the thorax. The morbidity and mortality of penetrating esophageal trauma is

usually related to associated injuries including major vascular and airway structures.16 Blunt traumatic

perforation of the esophagus is exceedingly rare.

The most commonly referenced and discussed perforation is the spontaneous one. This results from a

sudden increase in intraesophageal pressure and associated with hyperemesis, childbirth, seizure, or

prolonged coughing. Boerhaave syndrome is of special historical note, wherein patients develop

perforation of the distal esophagus following extensive ingestion of food or alcohol. What follows is

violent emesis resulting in a distal esophageal perforation, frequently into the left chest. The syndrome

was named after Herman Boerhaave, who provided a detailed account of this condition in 1723 through

a postmortem correlation of the perforation found in the High Admiral of the Dutch Navy, Baron Van

Wassenaer.17 Legend has it that the admiral attempted to relieve his postprandial discomfort by selfinduced vomiting after having feasted on roast duck and beer.

ETIOLOGY

Table 43-1 Causes of Esophageal Perforation

Clinical Features of Esophageal Perforation

The presenting features depend on the location of perforation and the time interval from perforation to

presentation. Underlying comorbidities may also have an influence on the presentation and the patient’s

physiologic reserve. Patients with cervical perforation present with dysphagia, neck pain, dysphonia,

and subcutaneous neck emphysema. Intrathoracic perforations present with signs and symptoms of

mediastinitis as follows: chest pain, tachycardia, tachypnea, fever, and leukocytosis. Perforations of the

intra-abdominal esophagus may present as an acute abdomen with signs and symptoms as follows: pain,

tachypnea, tachycardia, fever, and leukocytosis. More significant perforations and longer intervals to

presentation contribute to the features of systemic sepsis, shock, and rapid deterioration.

Diagnosis

The diagnosis of esophageal perforation needs to begin with the clinician and their index of suspicion.

Any patient who presents with pain following an endoscopic intervention needs to be carefully

evaluated for perforation. The initial workup involves careful history and physical examination,

laboratory studies including leukocyte count, and chemistry panel for acidosis. Chest x-ray is a good

screening test for other diagnoses in the differential. Contrast esophagography remains the gold

standard for diagnosis as the study will diagnose and localize the site of the perforation. This study also

gives important information about coexisting pathology of the esophagus and the degree of

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extravasation and its trajectory. Water-soluble contrast (e.g., Gastrograffin) is the initial agent utilized,

followed by thin barium to enhance the sensitivity of the study. Water-soluble agents demonstrate 50%

of cervical perforations and 80% of intrathoracic perforations.18 Thin barium will identify 60% of

cervical and 90% of intrathoracic perforations.19 If there is a chance of aspiration or high concern of

tracheoesophageal fistula, thin barium should be used from the outset because the hyperosmolar watersoluble contrast agents may cause rapid pulmonary edema and respiratory compromise.

Computerized tomography (CT) scan is very useful in the diagnostic evaluation of the patient with

concern for esophageal perforation. Often a CT scan is the first test obtained following a chest x-ray as

it affords the clinician the ability to narrow the differential diagnosis. CT may be useful for identifying

the site of perforation and any associated mediastinal or pleural fluid collections. It is very common for

a CT scan finding to prompt thoracic surgical consultation or transfer and there is much additional

information about the patient’s overall status which is routinely utilized in the management plan.

However, it should be emphasized that the barium swallow should be the procedure of choice unless

there is a significant risk of aspiration.

Flexible esophagoscopy should be utilized liberally in the diagnostic evaluation of the esophagus and

in the planning of treatment options, and in a significant number of cases it can also be used for

intervention. The scope is utilized to directly visualize the area of perforation and identify any potential

associated pathology. It has a sensitivity of over 95% and a specificity of 80% or even higher depending

on the experience of the physician.20 We routinely perform flexible endoscopy as the initial step in the

operating room when considering all options for patient management. Concern has been expressed by

some that the instrumentation of the esophagus and insufflation of air can worsen the extent of injury

and pathology and we would agree with that in inexperienced hands. With care and experience,

however, the flexible scope can be used safely and more effectively delineates the problem to aid in

surgical decision-making that follows. The vast majority of patients will require an endoscopic

evaluation at some point and the timing of this will depend on clinical presentation and findings on

radiologic imaging. For very small leaks present in stable and nontoxic patients, when the contrast

study shows little or no extravasation, we may opt to hold off on an endoscopy in select cases.

Management

3 The treatment of esophageal perforation is managed according to the clinical presentation which

includes the location of the perforation, the degree of soilage, and the clinical condition of the patient.

Generally speaking, the sooner diagnosis and a treatment plan is carried out, the better the outcome.

The goal of treatment is to stabilize the patient, stop ongoing soilage, control the infection, and

reestablish esophageal continuity. Algorithm 43-1 provides general guidelines to the management of

patients with esophageal perforations.

Nonoperative Treatment

For properly selected patients with esophageal perforation, nonoperative management may be

appropriate. Generally, as thoracic surgeons, we err on the side of operative exploration intervention

given the potential gravity of missing a clinically significant esophageal perforation with mediastinal

soilage. Reports of nonoperative management date back to the 1960s in which successful management

was accomplished in 18 highly selected patients with only one death.21 In the late 1970s, criteria were

published for nonoperative management.22 Current guidelines for patients that can be managed

nonoperatively include those with no transmural perforation or for whom transmural perforation

represents a contained process. There must also be no associated esophageal pathology such as

malignancy and no signs of systemic illness. The management of the nonoperative approach begins with

the administration of broad-spectrum antibiotics (including antifungals), the suspension of oral intake,

and vigilant clinical monitoring. The patient is followed clinically and reimaged as needed, generally

within 48 to 72 hours with an esophagram and CT scan. If the patient improves during that time and

testing is favorable, the diet may be advanced to clear liquids with the patient eventually being

discharged on oral antibiotics and full liquids until reevaluation with imaging in clinic in 2 weeks. Any

signs of sepsis such as fever, tachycardia, or leukocytosis suggest failure of this approach and further

intervention should be expeditiously considered.

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