In Brief

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A wide spectrum of benign esophageal disease is encountered in general medical practice. Billions of dollars are spent each year in the United States alone for over-the-counter and prescription medications to control the overt manifestations of gastroesophageal reflux disease (GERD), not to mention expenditures on other medical or surgical treatments for esophageal anatomic or functional disorders. In addition, many presentations of benign esophageal disease are occult; patients experiencing typical symptoms of heartburn, regurgitation, or dysphagia are only a minority of those suffering the consequences of esophageal pathophysiology. Some of the most common complaints for which patients seek medical attention, such as chest pain, cough, wheezing, or sore throat, can be attributed to esophageal pathology or at least must be considered in the differential diagnosis.

Symptoms suggestive of benign esophageal disease may be difficult to differentiate from more life-threatening conditions; examples include the determination of whether chest pain is secondary to GERD or esophageal spasm versus coronary artery disease and whether dysphagia is secondary to an esophageal motility disorder versus an esophagogastric carcinoma. Esophageal disorders also can lead to severe health problems in a more chronic or subtle fashion, such as when repetitive aspiration from GERD or abnormal esophageal motility leads to the insidious onset of pulmonary fibrosis, or chronic GERD leads to the development of an esophageal adenocarcinoma. Given the simplicity of the esophagus, an organ best characterized as a muscular pump bordered by 2 sphincters and without known endocrine, exocrine, immunologic, digestive, absorptive, or secretory functions, the frequency, diversity, and potential severity of the various manifestations of esophageal pathology is mind-boggling.

The esophagus holds the unique anatomic distinction among the visceral organs of occupying 3 discrete body cavities: the neck, thorax, and abdomen. As a result, several surgical disciplines consider portions of the esophagus within their purview. General surgeons should be well versed in operations involving the gastroesophageal junction, with laparoscopic specialists often receiving additional focused training in antireflux surgery and distal esophageal myotomy for esophageal motility disorders. Thoracic surgeons may utilize any of several approaches to the intrathoracic esophagus and should be comfortable operating on each side of the diaphragm. Otolaryngologists may not only evaluate the patient complaining of sore throat, hoarseness, or laryngitis, but may also perform operations involving the upper esophageal sphincter or cervical esophageal segment. Of course, these boundaries of specialization are blurred depending on the training and experience of the individual practitioner.

The surgical esophagologist must possess a thorough understanding of normal and pathologic esophageal anatomy and physiology, as well as a strong background in clinical assessment and foregut diagnostics to make appropriate management decisions. Because symptoms generally are not pathognomonic for esophageal disease, are varied in their presentation, and can be unreliable in determining etiology, using symptoms alone to guide therapy can be misleading. In addition, each of the available esophageal diagnostic studies has strengths and limitations that must be understood to determine their place in the assessment of esophageal disease. Only through consideration and consolidation of both subjective and objective findings can the optimal treatment course be determined.

In most cases, the symptoms experienced by patients with esophageal disorders are minor, intermittent, and easily controllable with medications and subtle dietary or lifestyle modifications. In more advanced cases, patients may be referred for surgical therapy intended to improve foregut function or correct anatomic abnormalities. For some patients, however, the severity of esophageal dysfunction and associated symptoms is such that esophageal resection with replacement is the most appropriate option. Given the large differences in the magnitude of invasiveness and risk associated with these various interventions, considerable judgment may be necessary on the part of the evaluating physician in determining the most appropriate course of therapy.

Acid suppressive or neutralizing medications are frequently utilized by patients for self-treatment of reflux symptoms without seeking physician input. With the availability of generic and over-the-counter proton pump inhibitors and histamine 2-receptor antagonists, this practice likely is more common than ever. Such treatments, however, address only the acid component of the gastric refluxate and do not control other potentially injurious agents such as bile, pepsin, or pancreatic enzymes that may be inflammatory or carcinogenic in nature. Although current medical therapy often is effective at controlling GERD-related symptoms and complications, medications do not address the underlying pathophysiology of the disease: the incompetent lower esophageal sphincter (LES). Antireflux surgery, on the other hand, does attempt to restore the antireflux barrier.

Surgical therapy for GERD was revolutionized by the introduction of laparoscopic Nissen fundoplication. The attractiveness and utilization of surgery for control of reflux increased dramatically as the laparoscopic approach became widely available. Perioperative and long-term outcomes after open and laparoscopic antireflux procedures generally have been favorable as judged by both symptomatic and objective measures. Despite this fact, the utilization of fundoplication recently has been on the decline. As surgical therapy for GERD continues to be scrutinized, contemporary data are important regarding perioperative complications, costs, and long-term symptomatic and objective outcomes. Such data are critical in countering misconceptions about the efficacy and durability of fundoplication and provide a meaningful baseline against which alternative therapies should be judged.

Endoscopic therapies also have been introduced as a means to reestablish LES competence in a less invasive manner than traditional surgical intervention. Of the several technologies that have reached the clinical marketplace to date, however, none has survived. Despite this recent history of failures, endoscopic antireflux devices continue to emerge. The fact that interest remains in endoscopic therapies highlights the importance that is placed on correcting the incompetent LES as therapy for GERD and preventing reflux of all of the components of gastric juice. Whether endoscopic approaches ultimately prove successful awaits trials of future generations of devices.

Esophageal motility disorders are another subset of benign esophageal conditions for which patients commonly seek medical or surgical therapy. Of these disorders, achalasia is the best defined and most widely treated. Although nonsurgical options have their place in the therapeutic armamentarium for achalasia, laparoscopic distal esophageal myotomy, typically with addition of a partial fundoplication, has become the standard of care in most centers for patients deemed at suitable risk for surgery. Just as laparoscopic Nissen fundoplication dramatically increased the application of surgery for control of GERD, so has minimally invasive myotomy expanded the use of surgery for treatment of motility disorders. Although nonachalasia motility disorders less frequently lead to surgical intervention, an associated pulsion diverticulum, whether cervical or epiphrenic in location, commonly requires operative therapy.

The skilled esophageal surgeon must be capable of assessing and treating failures of surgical intervention. Considerable judgment is required in deciding whether a failed operation can be remediated by revisional surgery or whether an extirpative procedure with foregut reconstruction is best. A thorough assessment of symptoms, including their characterization, frequency, and severity, as well as a determination of patient comorbidities is essential in deciding whether the anticipated benefits of foregut reconstruction outweigh the inherent risks, especially in light of an outcome that does not typically restore eating to normal. A variety of operative approaches and esophageal replacement conduits are available for reconstructing the upper gastrointestinal tract; they must be understood and mastered by the surgeon considering esophageal replacement surgery.

As end-stage esophageal disease is infrequently encountered in the general medical community, and as a definite volume-outcome relationship exists for foregut reconstruction as for other major surgical procedures, patients presenting with the manifestations of severe esophageal disorders are best treated in a specialty center with considerable experience in managing such conditions. When patients are appropriately selected, and when surgery is performed in a center of expertise, the outcomes following foregut reconstruction generally are favorable with a low rate of mortality, acceptable morbidity, and good long-term alimentary function.