The esophagus connects the mouth to the stomach. Although esophageal cancer is uncommon, accounting for only 1.5% of newly diagnosed invasive cancers, it is highly virulent and unfortunately often diagnosed late in its course. Approximately 17,000 new cases of esophageal cancer are diagnosed in the United States each year.
Two major types of cancer occur in the esophagus. In the past, squamous cell cancer, occurring in the upper third of the esophagus, was the most common. Recently, a second type of cancer, adenocarcinoma, has become more prevalent and tends to occur in the lower two thirds of the esophagus.
Depending on the stage of the cancer at the time of diagnosis, a wide array of treatment options are available including a new minimally invasive procedure for patients with early-stage cancer of the esophagus that provides the option for removing the tumor while keeping their esophagus. Albany Med’s thoracic surgeon Thomas Fabian, M.D., is one of just a handful of surgeons nationwide performing the new procedure.
Surgical resection is the mainstay of therapy. Recent curative treatment strategies have included multimodality approaches that combine some form of chemotherapy, radiation therapy, and surgery. With these changes, survival rates have risen dramatically, with some stages having 40-70 percent survival at five years.
When curative therapy is unavailable, there are a number of palliative therapies that can provide long-term palliation of swallowing, pain, bleeding, and obstruction. These include esophageal dilation, laser ablation of the tumor, photodynamic therapy, and esophageal stenting.
Minimally invasive esophagectomy
In addition to innovative therapies, there are also improvements in old therapies. Minimally invasive esophagectomy is a procedure developed and performed at a few specialized centers across the country, requiring training specifically focused on the procedure. It allows for potentially curative resection of the esophagus through smaller, less painful incisions, while observing cancer surgery principles. The benefits of this approach may include less pain, shorter recovery, more complete resection, less immune suppression from surgical stress, fewer complications, and a lower operative death rate.
Benign Esophageal Disease
The esophagus is a muscularized tube that pushes food and liquids from the mouth to the stomach. Patients can suffer from various motor dysfunctions of the esophagus, which can result in symptoms, such as difficult and painful swallowing, heartburn, and chest pain. The results of these disorders can result in strictures, Barrett's esophagus, or esophageal diverticular disease. There are therapies for many of these disorders, each of which has different risks and benefits.
Gastroesophageal Reflux (GERD)
Gastroesophageal Reflux is a situation where the muscle separating the esophagus from the stomach fails. In normal patients the lower esophageal sphincter protects the esophagus from gastric contents. It also needs to relax normally to allow food to pass from the esophagus to the stomach. Sometimes these normal relationships are altered either from muscle failure or anatomic defect such as a hiatal hernia. Symptoms include classic heartburn, regurgitation, chest pain, cough, sore throat, and adult onset asthma to name a few.
Therapy is usually initiated with behavioral modification and proton pump inhibitors. For the vast majority suffering from GERD, this therapy is effective. Unfortunately, there are others whose symptoms are not relieved, or whose medication ceases to be effective. In certain patients, endoscopic and surgical treatments can be offered. Endoscopic therapies such as the STRETA procedure, Enteryx, and Plicator may be appropriate. Others are treated by laparoscopic nissen fundoplication.
There are various hiatal hernias. Essentially some of the abdominal contents have pushed from the abdomen into the chest through a defect in the diaphragm. Many patients with small hiatal hernias are asymptomatic and do not need treatment. However, some hiatal hernias are large and cause symptoms, such as difficulty swallowing, early satiety, pain, and shortness of breath. In these cases, operative repair with either laparoscopic or open repair is often required.
Achalasia is a situation where the lower esophageal sphincter (LES), which separates the esophagus from the stomach, fails to relax. In normal patients this muscular zone keeps gastric food from moving back up the esophagus. The muscle also needs to relax appropriately to allow food to pass from the esophagus to the stomach. When this fails to occur, patients develop difficulty with swallowing and eating. There are various treatments, including botox injections into the LES, pneumatic dilation, and laparoscopic Heller myotomy.