BENIGN TUMORS OF THE ESOPHAGUS

BENIGN TUMORS OF THE ESOPHAGUS

In ordinary surgical practice, benign tumors of the esophagus are rarely encountered. For instance, at the Mayo Clinic, Moersch discovered 59 (0.3 percent) benign tumors among 18,459 patients who complained of dysphagia. Most of the benign mucosal tumors, such as polyps and papillomas, are seen by the endoscopist rather than by the surgeon and are usually removed locally through the esophago – scope. The importance of careful histological study of these tumors hardly needs emphasis.

By far the most common benign tumor is the leiomyoma, and this is the one which is referred to the surgeon when it attains sufficient dimensions to cause some degree of dysphagia. These myomas, found most often in the middle and lower thirds of the esophagus, occur singly or in multiple arrangement. They arise from the circular muscle layer and vary greatly in size. In my experience, they are always encapsulated and never involve the esophageal mucosa.

The degree of dysphagia produced by these tumors will depend largely on their size and extent of impingement on the esophageal lumen. I have seen fairly large lobulated tumors practically encircling the organ with little dysphagia. The diagnosis is made by roentgen examination. This discloses the characteristic appearance of a smoothly outlined tumor with sharply defined borders (Fig. 22). Esophagoscopy confirms the bulging of the tumor into the lumen, and always discloses an intact overlying mucosa. With the x-ray films and these findings on endoscopy, biopsy is not necessary. As a matter of fact, I would urge that biopsy be avoided. Biting into the normal mucosa could complicate matters for the surgeon should operation for the removal of the myoma be undertaken soon after.

myoma of the lower esophagus

Fig. 22. Roentgenogram indicating the smooth appearance of a myoma of the lower esophagus.

 

The surgical treatment of myoma or fibroma of the esophagus is concerned mainly with the enucleation of an encapsulated tumor without entering the lumen of the organ. If the tumor is located in the middle third of the organ, a right transthoracic approach is preferable. A tumor located in the lower third is best treated by a left transthoracic approach. In either case, the chest is opened by an intercostal incision as described in the section on epiphrenic diverticulum. Gradual opening of the rib-spreader over a 10-minute period affords a wide exposure without rib fracture. The mediastinal pleura overlying the esophagus is incised, and the esophagus is freed bluntly from the mediastinum. Holding the tumor-bearing portion of the esophagus between the index finger and thumb of the left hand, the surgeon incises the thinned-out longitudinal musculature overlying the tumor (Fig.23).

BENIGN TUMORS OF THE ESOPHAGUS

Fig. 23. Details of the operation for myoma of the esophagus showing the mobilization of the esophagus, the incision in the muscularis, enucleation of the myoma, and repair of the muscularis.

When the proper plane is reached, the tumor may then be easily enucleated without injuring the mucosa. The divided musculature is now repaired with interrupted sutures of fine silk. The esophagus is replaced in the mediastinum, and the incised pleura is closed with interrupted sutures. The chest may be closed without underwater drainage, provided that full expansion of the lung is maintained by the anesthetist until the wound dressing is applied.

The postoperative care of these patients should present no difficulties. Swallowing of fluids may be started the following day with rapid increase in the food intake thereafter. A postoperative hospital stay of seven or eight days should suffice.

The literature contains instances of diffuse myomas of portions of the esophagus where it was impossible to accomplish enucleation of the tumors. This necessitated resection of the organ with esophagogastric anastomosis. This must be an extremely rare occurrence nowadays. In our group of 16 patients with esophageal myomas, enucleation was possible in each instance. None of the patients died.

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