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Key Points

  • image Benign esophageal disease is common and is best evaluated with thorough physiologic testing (high resolution esophageal motility, 24-hour ambulatory pH measurement, and/or esophageal impedance testing) and anatomic testing (esophagoscopy, video esophagography, and/or computed tomography [CT] scanning).

  • image Gastroesophageal reflux disease (GERD) is the most common disease of the gastrointestinal tract for which patients seek medical therapy. When GERD symptoms (heartburn, regurgitation, chest pain, and/or supraesophageal symptoms) are troublesome despite adequately dosed PPI, surgical correction may be indicated.

  • image Barrett’s esophagus is the transformation of the distal esophageal epithelium from squamous to a specialized columnar epithelium capable of further neoplastic progression. The detection of Barrett’s esophagus on endoscopy and biopsy increases the future risk of cancer by >40x compared to individuals without Barrett’s esophagus.

  • image Giant hiatal hernia, otherwise known as paraesophageal hernia, should be repaired when symptomatic or associated with iron deficiency anemia. Laparoscopic hiatal hernia repair with fundoplication is the most common approach to repair.

  • image Achalasia is the most common primary esophageal motor disorder. It is characterized by an absence of peristalsis and a hypertensive nonrelaxing lower esophageal sphincter. It is best treated with laparoscopic Heller myotomy and partial fundoplication.

  • image Most esophageal cancer presents with dysphagia, at which time it has invaded the muscularis of the esophagus and is often associated with lymph node metastases. The preferred treatment at this stage is multimodality therapy with chemoradiation therapy followed by open or minimally invasive esophagectomy.


The esophagus is a muscular tube that starts as the continuation of the pharynx and ends as the cardia of the stomach. When the head is in a normal anatomic position, the transition from pharynx to esophagus occurs at the lower border of the sixth cervical vertebra. Topographically this corresponds to the cricoid cartilage anteriorly and the palpable transverse process of the sixth cervical vertebra laterally (Fig. 25-1). The esophagus is firmly attached at its upper end to the cricoid cartilage and at its lower end to the diaphragm; during swallowing, the proximal points of fixation move craniad the distance of one cervical vertebral body.

Figure 25-1.

A. Topographic relationships of the cervical esophagus: (a) hyoid bone, (b) thyroid cartilage, (c) cricoid cartilage, (d) thyroid gland, (e) sternoclavicular. B. Lateral radio-graphic appearance with landmarks identified as labeled in A. The location of C6 is also included (f). (Reproduced with permission from Shields TW: General Thoracic Surgery, 3rd ed. Philadelphia, PA: Lea & Febiger; 1989.)

The esophagus lies in the midline, with a deviation to the left in the lower portion of the neck and upper portion of the thorax, and returns to the midline in the midportion of the thorax near the bifurcation of the trachea (Fig. 25-2). In the lower portion of the thorax, the esophagus again deviates to the left and anteriorly to ...

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