Esophageal Cysts Treatment & Management

Medical therapy has no role in the management of esophageal cysts.

• Simple cysts are enucleated, whereas duplications are excised.^[5]
• 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, 6]} Also described in the literature is endoscopic treatment of esophageal duplications, which, essentially, create a lumen from the cyst into the esophageal lumen.^[2]

Preoperative workup should focus on 2 facets.

• A thorough history and physical examination is important to elucidate comorbid conditions that can be addressed prior to the operation, thus decreasing morbidity.
• A thorough radiological workup demonstrates the anatomy of the cyst and assists in the planning of the operation.

• Prior to induction of anesthesia, an epidural catheter is placed for pain control. Alternatively, an ON-Q pain pump (VQ OrthoCare, Irvine, Calif) 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, Mass) 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, 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.
• An alternative to VATS includes a posterolateral thoracotomy with the addition of the above steps.

• 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. An esophagram can be used to assess esophageal integrity.

• 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.

• The overall complication rate is very low.
• Most complications are inherent to the thoracotomy or VATS.
• Complications include pneumonia, persistent air leak, deep venous thrombosis, esophageal leak or pseudodiverticulum, vagus nerve paralysis, and wound infection.^[7]

• If the entire cyst is excised, recurrence is rare.
• The morbidity rate is low.
• Overall, most patients do well in both the short and long term.

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