A comprehensive understanding of the anatomy of the esophagus is critical before undertaking surgical procedures on the esophagus ( Fig. 35-1A-C ).

(Adapted from Hagen JA, DeMeester TR. Anatomy of the esophagus. In Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery, 5th ed, vol 2. Philadelphia: Lippincott Williams & Wilkins; 2000:1599.)

Indications

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  There are a variety of benign esophageal tumors. Generally arising from the muscularis propria layer with normal overlying mucosal layer, the vast majority of benign esophageal tumors are slow growing and remain undetected and asymptomatic. They are usually found incidentally during endoscopic or radiographic evaluation or at the time of operation for reflux. Large or strategically located tumors can be symptomatic, with 90% located in the middle and distal third of the esophagus. These tumors may require biopsy, regression therapy, and, in some cases, excision. About 5% of all detected benign esophageal tumors require surgery.

Classification of tumor type helps determine the best operative approach.

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  Leiomyoma are the most common, comprising nearly two thirds of all benign esophageal tumors. Most are found in the lower one third of the esophagus and are usually intramural. Leiomyoma rarely cause symptoms when smaller than 5 cm in diameter. When symptomatic, dysphagia and vague pain are the most common complaints.

  
  
  
  
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    On barium swallow, leiomyoma characteristically appear as smooth, crescent-shaped defects covered by smooth mucosa ( Fig. 35-2 ).

    
    

    
    

    
    

    

    
    

    (From Zwischenberger JB, Savage C, Bhutani MS. Esophagus. In Townsend CM Jr, Beauchamp RD, Evers RM, et al, eds. Sabiston Textbook of Surgery, 17th ed. Philadelphia: Saunders; 2004:1116.)

    
    
    
    
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    Esophagoscopy is performed in all cases. Characteristic endoscopic appearance is a submucosal bulge without stenosis, usually movable through the endoscope.

    
    
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    Recommended treatment is surgical excision for symptomatic leiomyoma and those larger than 5 cm. Asymptomatic leiomyoma or lesions smaller than 5 cm are followed periodically with barium swallow.

  
  
  
  
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  Intraluminal polyps are the second most commonly reported benign esophageal tumors and are more common in men than women (3 : 1). Due to the similarity of histologic findings of intraluminal polyps to fibroepithelial polyps, fibroma, fibrolipoma, and pedunculated lipomas, these are now all grouped under the name fibrovascular polyps . They usually occur in the upper esophagus and often are associated with the cricopharyngeous. The most common symptoms are dysphagia and regurgitation.

  
  
  
  
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    Barium swallow reveals the characteristic appearance of a smooth intraluminal sausage-shaped mass. Both barium swallow and esophagoscopy are recommended for diagnosis. Biopsy is not recommended because these polyps are quite vascular.

    
    
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    For tumors smaller than 4 cm, observation and periodic barium swallow assessment is recommended. For tumors larger than 4 cm, not amenable to endoscopic removal, recommended treatment is surgical excision using an external approach, such as video-assisted thoracoscopic surgery (VATS) or thoracotomy.

  
  
  
  
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  Squamous papilloma also are reported as benign esophageal tumors. They are most frequently isolated in the posterior wall of the distal third of the esophagus. They appear endoscopically as a warty, polypoid mass that is firm to the touch.

  
  
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  Box 35-1 provides a list of reported benign esophageal tumors.

  
  
  
  

  BOX 35-1

  
  

  Benign Esophageal Tumors

  
  

  
  

  
  

  
  
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    Leiomyoma

    
    
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    Fibrovascular polyp

    
    
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    Squamous cell papilloma

    
    
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    Granular cell tumor

    
    
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    Hemangioma

    
    
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    Congenital esophageal cyst

    
    
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    Bronchogenic cyst

    
    
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    Inflammatory fibroid polyp (eosinophilic granuloma)

    
    
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    Lymphangioma

    
    
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    Lipoma

    
    
  • 
    

    Neurofibroma

  
  

  
  

Common presenting symptoms of esophageal tumor are chest pain, dysphagia, odynophagia, regurgitation, bleeding, and respiratory compromise. Less common symptoms are thoracic pressure, anorexia, and weight loss.

A variety of tests may be ordered to determine a diagnosis.

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  Barium swallow

  
  
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  Endoscopy

  
  
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  Computed tomography to help characterize the tumor’s location and size

  
  
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  Endoscopic ultrasound (EUS)

  
  
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  More than three of these characteristics is predictive of malignancy.

  
  
  
  
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    Tumor diameter greater than 3 cm

    
    
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    Nodular shape

    
    
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    Ulceration depth greater than 5 mm

    
    
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    Heterogeneous echo

    
    
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    Presence of anechoic area

  
  

Biopsy is not recommended if endoscopic and radiographic examinations are consistent with diagnosis of benign tumor type for the following reasons.

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  Increased risk of mucosal perforation and inflammation complicates eventual surgical removal

  
  
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  Possibility of massive blood if vascular mass

Rationale for a surgical approach

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  Presence of symptoms

  
  
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  Excisional pathology excludes malignancy

  
  
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  If asymptomatic, operative intervention depends on likelihood of symptom development or malignant degeneration

Rationale for a nonsurgical approach

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  Malignant transformation is extremely rare.

  
  
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  Leiomyoma are slow growing.

  
  
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  There is a benign clinical course.

Contraindications to surgery

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  Insufficient patient cardiopulmonary reserve

  
  
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  Comorbidities that impair ability to tolerate general anesthesia

Prior surgery is not a contraindication; depending on the density of adhesions, contralateral VATS approach may be needed.