Surgical management of strictures of the lower thoracic esophagus.

An obstructing lesion of the lower thoracic esophagus should be evaluated carefully and appropriate surgical therapy planned to correct the abnormal physiology. Gastroesophageal reflux is the most frequent cause of esophageal stricture and usually can be managed effectively by dilatation of the esophagus, restoration of a competent lower esophageal sphincter, and repair of an associated hiatal hernia. Collis gastroplasty and a Belsey herniorrhaphy are useful when the esophagus is excessively shortened. Firm, fixed esophageal strictures may be treated by the Thal procedure accompanied by Nissen's fundoplication or by resection of the stricture and interposition of a colon graft or an achlorhydric tube. The management of other benign strictures secondary to scleroderma, ingestion of caustic substances, or benign neoplasms must be individualized. Most benign strictures may be cared for by dilatation; however, firm, fixed strictures should be resected. Wide surgical resection is indicated for primary malignant lesions of the lower thoracic esophagus that are localized or have limited lymph node metastasis.