Key Points

• Esophagectomy for benign disease has different considerations than one for carcinoma: (1) a longer life expectancy for the patient (greater importance of long-term functional results); (2) lack of preoperative chemoradiation therapy; and (3) a greater frequency of prior esophageal operations.
• Obtaining prior operative records is important in enabling the surgeon to plan the operation.
• There has been a decline in the number of esophagectomies being performed for anatomic obstructive pathology (e.g., reflux or caustic strictures) and more for neuromotor disease (i.e., achalasia and spasm) after prior unsuccessful operations, failed antireflux/hiatal hernia operations, and complications of complex endoscopic proceudres
• Functional results of esophageal replacement for benign disease should be assessed and reported in terms of the presence and degree of dysphagia, regurgitation, weight loss, post-vagotomy “dumping” symptoms, and patient satisfaction with ability to eat—not only in terms of the flow of barium down the conduit.
• When a free esophageal perforation occurs in a patient with intrinsic esophageal disease (e.g., carcinoma or a reflux or caustic stricture), esophagectomy is the best treatment option.

Patients with benign esophageal disease requiring esophageal resection and reconstruction differ in several ways from their counterparts with malignant disease: (1) longer life expectancy; (2) lack of neoadjuvant chemoradiation therapy; and (3) a frequent history of prior esophageal operations. Because of their longer life expectancy, those with benign disease serve as a better indicator of the functional results of esophageal substitution. For example, the development of reflux esophagitis is virtually inevitable after performance of a low intrathoracic esophagogastric anastomosis and is inversely related to the level of the anastomosis. . This may have relatively little practical significance when life expectancy is short, but an esophageal reflux stricture causing dysphagia after an esophagectomy for benign disease intended to provide comfortable swallowing represents a dismal outcome. For this reason, a low intrathoracic esophagogastric anastomosis for benign disease should be avoided whenever possible (Figure 1). The long-term results of esophagectomy and esophageal replacement for benign disease must be assessed not only in terms of length of survival after the operation but also for the ability to swallow a normal diet comfortably, emptying of the esophageal substitute, posturally related regurgitation and associated pulmonary complications, as well as post-vagotomy “dumping” symptoms (postprandial cramping and diarrhea, diaphoresis, and palpitations).

Figure 1

A, Barium swallow examination in a 74-year-old woman who had undergone a transabdominal distal esophagectomy and low esophagogastric anastomosis (arrow)for esophageal dysmotility. Subsequent gastroesophageal reflux and severe esophagitis resulted in anastomotic and multiple other esophageal strictures causing obstruction, aspiration pneumonia, and impaired nutrition. B, The patient underwent a transhiatal esophagectomy and conversion to a cervical esophagogastric anastomosis (marked with metallic clips). Her symptoms from gastroesophageal reflux and esophagitis were eliminated, bouts of recurrent pneumonia stopped, and her nutrition was restored. A low intrathoracic esophagogastric anastomosis for benign disease is to be avoided.

The current enthusiasm for neoadjuvant therapy before esophagectomy for locoregionally advanced cancer places a greater burden on the surgeon to ensure that his or her patient has physiologically recovered from this treatment and has recovered sufficiently to withstand an esophagectomy. Whether operating for benign or malignant esophageal disease, the pulmonary and nutritional consequences of impaired swallowing must be treated. Caloric supplementation through a nasogastric or enteric feeding tube is used as necessary, and vigorous preoperative pulmonary physiotherapy is instituted with treatment of pneumonia if present. A gastrostomy tube should be avoided if at all possible in order to avoid injury to the right gastroepiploic arcade that serves as the main vascular supply for the gastric conduit. The patient should use an incentive spirometer, walk 1 to 3 miles a day as tolerated, and absolutely stop smoking cigarettes.

Finally, an ever-increasing number of patients requiring esophagectomy for benign disease have undergone one or more prior esophageal operations, often making their esophagectomy a far greater technical challenge that is associated with greater blood loss than in the patient with carcinoma. Prior gastric surgery also can limit the options for esophageal reconstruction. It is important to obtain and review prior operative reports that describe whether a crural closure was performed with or without mesh, if the fundoplication was secured to the diaphragm, the length of a previous esophagomyotomy, whether inadvertent entry into the lumen occurred and was repaired, or whether a concomitant antireflux operation was performed. In the patient who has had a prior esophagomyotomy for achalasia or diffuse spasm, the exposed esophageal submucosa may become intimately adherent to the descending thoracic aorta, increasing the potential morbidity of esophagectomy. In those who have undergone multiple antireflux/hiatal hernia operations, takedown of a prior fundoplication without traumatizing the stomach to the point that it cannot be used as an esophageal substitute can be a major challenge. In such patients in whom the stomach is not a satisfactory esophageal replacement, the colon or small bowel must be evaluated for its suitability and prepared in the event that it is needed. This chapter reviews the challenges associated with esophagectomy for benign disease.