Benign Diseases of the Esophagus

The Division of Thoracic Surgery offers diagnostic and therapeutic services for benign esophageal disease.

The Massachusetts General Hospital Division of Thoracic Surgery offers diagnostic and therapeutic services for benign esophageal disease, including:

• Gastroesophageal reflux
• Re-operative gastroesophageal reflux surgery (Redo Nissen fundoplication)
• Achalasia
• Paraesophageal hernia
• Esophageal diverticula (Zenker's or Epiphrenic Diverticulum)
• Benign esophageal strictures that can cause swallowing problems
• Benign tumors, such as leiomyoma
• Esophageal cysts
• Barrett’s esophagus

Many patients with benign esophageal conditions can be treated with minimally invasive laparascopic or thoracoscopic procedures, which allow patients to have a significantly quicker recovery and return to function.

Gastroesophageal Reflux Disease

Mass General's thoracic surgery service offers a full range of diagnostic and therapeutic options for treating patients with gastroesophageal reflux disease (GERD). Options range from diagnosis with endoscopy to motility testing (swallowing) and acid-monitoring tests to expert radiology.

Surgery typically involves the creation of a new "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest point of the esophagus. This procedure is often referred to as a “Nissen fundoplication” or “fundoplication.”

Traditionally, "open" procedures for GERD required a large incision and a long, painful recovery. They were considered a last-resort treatment for extreme cases. Now, using laparoscopic techniques, Mass General surgeons can operate without a major incision. With five tiny openings instead of the traditional 8- to 10-inch long incision, most laparoscopic patients experience less pain, less scarring, shorter hospital stays and a quicker recovery than patients undergoing the open procedure. Patients typically leave the hospital one to two days after surgery.

Re-operative Gastroesophageal Reflux Surgery (Redo Nissen Fundoplication)

Occasionally, previous operations for GERD fail. Symptoms may be a return of heartburn or difficulty eating (dysphagia). The thoracic surgery division at Mass General is expert in evaluating patients with new symptoms following previous reflux surgery and is skilled in re-operative reflux surgery. Surgeons can often complete these operations with laparoscopic techniques similar to those described above.

Achalasia

A failure of the “valve” and muscles at the distal end of the esophagus to relax and a lack of “pumping” or peristaltic activity within the esophagus is referred to as achalasia. This dysfunction of the esophagus can lead to difficulty swallowing and frequent regurgitation of food. With the correct diagnosis, which involves imaging the esophagus with radiographic studies and evaluating its function, surgery can provide significant relief from symptoms.

The surgical approach (Heller myotomy) to treating achalasia involves “splitting” the muscles of the distal esophagua that fail to relax. This procedure was traditionally performed through a large incision that involves spreading the ribs. However, minimally invasive techniques are now available. Again, similar to procedures for GERD, patients have less scarring, shorter hospital stays and faster recovery.

Paraesophageal Hernia

Mass General thoracic surgeons perform a minimally invasive repair of paraesophageal hernias, a condition where the stomach pushes through the diaphragm (hiatus) alongside the esophagus to lie in the chest. Rarely, other abdominal organs (intestine, spleen, and colon) may also push into the chest. Symptoms range from vague, nonspecific abdominal complaints such as feeling full after a meal and indigestion to gastrointestinal bleeding.

If not treated, the hernia can grow and result in twisting (volvulus) of the stomach (possibly leading to gangrene), which requires emergency surgical treatment. When early symptoms present, there is an opportunity to repair the paraesophageal hernia laparoscopically rather than with an open incision through the abdomen or chest. Again, with five tiny incisions, the stomach is returned to the chest and the defect in the diaphragm repaired. The hospital stay is frequently one to two days.

Zenker's and Epiphenic Diverticulum

Motility disorders (disordered or uncoordinated swallowing) of the esophagus often lead to “outpouchings” or diverticulae of the esophagus. Symptoms are sometimes quite subtle, and can range from regurgitation of undigested food, difficulty swallowing, aspiration, or recurrent pneumonias. The most common location for diverticulae is in the cervical esophagus, referred to as Zenker’s diverticulum.

Zenker's diverticulae can be approached through an open technique involving a small incision in the neck. In certain patients, a Zenker's diverticulum can be treated with a transoral procedure that does not involve an incision and produces excellent results.

“Outpouchings” of the esophagus that develop lower in the chest are referred to as epiphrenic diverticulae. These diverticulae can be treated in a variety of ways. Certain patients are candidates for an advanced thoracoscopic procedure that does not involve a large incision and spreading the ribs.

We have had a long-standing interest in these conditions and have treated both the underlying motility disorder and the diverticulum.

Esophageal Cysts

There are two forms of esophageal cysts:

• Simple epithelial-lined cysts
• Esophageal duplication cysts, which are an embroyologic duplication of a portion of the muscle and submucosa of the esophagus without epithelial duplication

Diagnosis is aided by the relatively recent developments of CT scans and endoscopic ultrasonography. Treatment is currently moving from thoracotomy to less invasive procedures.

Barrett’s Esophagus

The Mass General Thoracic Surgery Service offers a full range of diagnostic and therapeutic options for patients with Barrett’s esophagus (changes in the distal esophagus that are potentially malignant).

Barrett’s esophagus is thought to be secondary to long-standing gastroesophageal reflux damaging the distal esophagus. The pathologic changes to the lining of the esophagus with Barrett’s esophagus can range from having no dysplasia to low grade dysplasia (or changes potentially a precursor to cancer) to high-grade dysplasia. When high-grade dysplasia is found on esophageal biopsy, there is an estimated risk of 20-30% that an early-stage cancer may also be present.

Mass General thoracic surgeons specialize in evaluating patients with Barrett’s esophagus and following these patients with surveillance endoscopy/biopsies of the esophagus to monitor progression/regression of the disease. In addition, the Mass General thoracic surgery service counsels patients with high-grade dysplasia on various treatment options.

The different therapeutic options for a patient with Barrett’s esophagus and high-grade dysplasia include:

• Endoscopic techniques
• Esophagectomy (removal of the esophagus and possible cancer)

Surgeons use an individualized approach with each patient, as patients may have differences in pathology, associated medical problems, age, and other factors affecting the decision-making process. Surgeons may perform esophagectomies with both open techniques and with a state-of-the-art minimally invasive approach employing laparoscopic and thoracoscopic techniques, avoiding large incisions.