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Esophageal Cysts Treatment & Management

  • Author: Dale K Mueller, MD; Chief Editor: Jeffrey C Milliken, MD  more...
 
Updated: Dec 16, 2015
 

Approach Considerations

Medical therapy has no role in the management of esophageal cysts. All esophageal cysts should be evaluated and, eventually, resected, except in those situations where the patient's other medical ailments prohibit operation. Given that nearly 75% of patients with esophageal cysts eventually become symptomatic, cysts should be resected when they are diagnosed.

The future of the treatment of esophageal cysts lies in the advancement of minimally invasive operative techniques, which will lessen morbidity and mortality. Endoscopic treatment has been reported as a feasible and reasonable alternative.[5] Robotic-assisted thoracic surgery has also been used for resection of an esophageal cyst.[6]

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Surgical Therapy

Simple cysts are enucleated, whereas duplications are excised.[7]  Previously, a posterolateral thoracotomy was required to remove the cyst or the duplication; however, video-assisted thoracoscopic surgery (VATS) is currently used to enucleate cysts and resect duplications, and it is the procedure of choice.[1, 8, 9] Also described in the literature is endoscopic treatment of esophageal duplications, which, essentially, creates a lumen from the cyst into the esophageal lumen.[2, 5]  Laparoscopic excision of intra-abdominal esophageal cysts has been described as well.[10, 11]

Preparation for surgery

Preoperative workup is based on the following two points:

  • A thorough history and a careful physical examination are important for elucidating comorbid conditions that can be addressed before the operation, thus decreasing morbidity
  • A thorough radiologic workup demonstrates the anatomy of the cyst and assists in the planning of the operation

Operative details

Before induction of anesthesia, an epidural catheter is placed for pain control. Alternatively, an ON-Q pain pump (VQ OrthoCare, Irvine, CA) can be placed at the time of operative intervention. Anesthesia is administered, and a double-lumen endotracheal tube is placed. The patient is then placed in the full lateral position.

A non–rib-spreading thoracotomy is performed (3-6 cm), with an additional Thoracoport (Tyco Healthcare, Mansfield, MA) used for visualization. Esophageal muscle fibers are carefully separated to expose the cyst. Blunt dissection is then used to enucleate the cyst. If a duplication is present, it is excised in a similar manner. During dissection, it is important to preserve both vagus nerves and the phrenic nerves.

After the lesion is removed, the muscle layers are reapproximated, thus preventing pseudodiverticula formation. Simultaneous esophagoscopy to illuminate the esophagus assists in visualization of the mucosa. Chest tube(s) is placed, and the incisions are closed in standard fashion.

Alternatives to VATS include robotic-assisted thoracoscopic surgery[6] and a posterolateral thoracotomy.

Postoperative care

Most patients do well, with minimal morbidity. Aggressive pulmonary toilet and early mobilization prevents pulmonary complications. Adequate analgesia is essential to patient cooperation with pulmonary toilet.

If the mucosa was not violated, the patient can be started on liquids within 1-2 days of the operation. If the mucosa was violated, then placement of a drain assists in determining the presence of a leak. Esophagography can be performed to assess esophageal integrity.

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Complications

The overall complication rate is very low. Most complications are inherent to the thoracotomy or to VATS. Complications that may develop include the following[12] :

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Long-Term Monitoring

Patients require close follow-up care. Pseudodiverticulum can develop if the muscle is not reapproximated. Complications of vagal injury develop if these nerves are not preserved. Recurrence is rare, especially if the entire cyst was excised.

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Contributor Information and Disclosures
Author

Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine

Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society

Disclosure: Received consulting fee from Provation Medical for writing.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

Daniel S Schwartz, MD, FACS is a member of the following medical societies: Society of Thoracic Surgeons, Western Thoracic Surgical Association, American College of Chest Physicians, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Christian Birkedal, MD, and J Thomas Williams, MD, to the development and writing of this article.

References
  1. Cioffi U, Bonavina L, De Simone M, Santambrogio L, Pavoni G, Testori A. Presentation and surgical management of bronchogenic and esophageal duplication cysts in adults. Chest. 1998 Jun. 113(6):1492-6. [Medline].

  2. Will U, Meyer F, Bosseckert H. Successful endoscopic treatment of an esophageal duplication cyst. Scand J Gastroenterol. 2005 Aug. 40(8):995-9. [Medline].

  3. Herbella FA, Tedesco P, Muthusamy R, Patti MG. Thoracoscopic resection of esophageal duplication cysts. Dis Esophagus. 2006. 19(2):132-4. [Medline].

  4. Tapia RH, White VA. Squamous cell carcinoma arising in a duplication cyst of the esophagus. Am J Gastroenterol. 1985 May. 80(5):325-9. [Medline].

  5. Tang X, Jiang B, Gong W. Endoscopic submucosal tunnel dissection of a bronchogenic esophageal cyst. Endoscopy. 2014. 46 Suppl 1 UCTN:E626-7. [Medline].

  6. Obasi PC, Hebra A, Varela JC. Excision of esophageal duplication cysts with robotic-assisted thoracoscopic surgery. JSLS. 2011 Apr-Jun. 15 (2):244-7. [Medline].

  7. Aldrink JH, Kenney BD. Laparoscopic excision of an esophageal duplication cyst. Surg Laparosc Endosc Percutan Tech. 2011 Oct. 21(5):e280-3. [Medline].

  8. Barbetakis N, Asteriou C, Kleontas A, Papadopoulou F, Tsilikas C. Video-assisted thoracoscopic resection of a bronchogenic esophageal cyst. J Minim Access Surg. 2011 Oct. 7(4):249-52. [Medline]. [Full Text].

  9. Lee SY, Kim HY, Kim SH, Jung SE, Park KW. Thoracoscopic resection of a cervical esophageal duplication cyst in a 3-month-old infant: a case report. J Pediatr Surg. 2013 Apr. 48 (4):873-5. [Medline].

  10. Bhamidipati C, Smeds M, Dexter E, Kowalski M, Bazaz S. Laparoscopic excision of gastric mass yields intra-abdominal esophageal duplication cyst. Thorac Cardiovasc Surg. 2013 Sep. 61 (6):502-4. [Medline].

  11. Castelijns PS, Woensdregt K, Hoevenaars B, Nieuwenhuijzen GA. Intra-abdominal esophageal duplication cyst: A case report and review of the literature. World J Gastrointest Surg. 2014 Jun 27. 6 (6):112-6. [Medline].

  12. Martin JT, Cibull ML, Zwischenberger JB, Reda HK. Infection of an esophageal cyst following endoscopic fine-needle aspiration. Int J Surg Case Rep. 2011. 2(6):144-6. [Medline]. [Full Text].

  13. Fernando HC, Erdem CC, Daly B, Shemin RJ. Robotic assisted thoracic surgery for resection of an esophageal cyst. Dis Esophagus. 2006. 19(6):509-11. [Medline].

  14. Harvell JD, Macho JR, Klein HZ. Isolated intra-abdominal esophageal cyst. Case report and review of the literature. Am J Surg Pathol. 1996 Apr. 20(4):476-9. [Medline].

  15. St-Georges R, Deslauriers J, Duranceau A, Vaillancourt R, Deschamps C, Beauchamp G. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult. Ann Thorac Surg. 1991 Jul. 52(1):6-13. [Medline].

 
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CT scan of esophageal cyst demonstrated by the white line.
 
 
 
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