Esophageal Cysts Treatment & Management
- Author: Dale K Mueller, MD; Chief Editor: Jeffrey C Milliken, MD more...
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. Robotic-assisted thoracic surgery has also been used for resection of an esophageal cyst.
Simple cysts are enucleated, whereas duplications are excised. 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
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 and a posterolateral thoracotomy.
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.
The overall complication rate is very low. Most complications are inherent to the thoracotomy or to VATS. Complications that may develop include the following :
Persistent air leak
Esophageal leak or pseudodiverticulum
Vagus nerve paralysis
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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