Introduction

In his History of Surgery of the esophagus Lyman A. Brewer III [1] highlights the oldest report on surgery of the esophagus in the “Smith Surgical Papyrus” (Figure 1). This is the oldest scientific document in ancient civilization. It dates from the 16 century BC but there is speculation that it may have been conceived as early as between 3000-2500 BC. After lying in a tomb in Thebes, Egypt, for over 3,000 years, the papyrus was sold to the antiquities dealer Edwin Smith in 1862. It was eventually given to the New York Historical Society by his daughter and rediscovered by J.H. Breasted, an archeologist and Egyptologist at the University of Chicago, who completed the first translation in 1930 [2].

Figure 1

Smith Papyrus.

The Edwin Smith papyrus is a scroll of 4.68 meters or 15.3 feet in length. The vast majority of the papyrus is concerned with trauma and surgery, in total there are 48 cases of injury. Case 28 describes recommendations for “Practices for a wound in the throat” as follows “...if you treat a man for a gaping wound in his neck obstructing his windpipe so that if he drinks water he has to choke and it comes out of the mouth of his wound and it is inflamed and he gets a high fever from it you have to fasten that wound with stitching...”.

It is conceivable that Egyptian medicine influenced ancient Greek and Roman medicine via Galenus (129-199 AD) who studied medicine for five years in Alexandria. His theories dominated Western and Arab medicine for almost 15 centuries. Abu-Marwan Abdel-Malik Ibn Zuhr, known as Avenzoar in the 12th century, was the greatest physician of the Western Caliphate. He was born and lived in what today corresponds to modern-day Spain (Figure 2). He developed the experimental methodology to evaluate new or controversial surgical procedures. One of these was tracheostomy in the resuscitation of life- threatening suffocation due to upper airway obstruction. As to the esophagus, he stated that a silver or tin cannula should be placed in the throat of patients who were unable to swallow to permit the ingestion of liquids [3]. This was the first attempt at stenting!

Figure 2

Abu-Marwan Abdel-Malik Ibn Zuhr known as Avenzoar.

In the Ottoman period, Şerefeddin Sabuncuoğlu (1385 to 1470?), was a famous Turkish surgeon who lived in the fifteenth century. He wrote Cerrahiyyet’ül Haniyye (Imperial Surgery), the first illustrated surgical textbook in the Turkish-Islamic medical literature, in 1465 at the age of 80 years. He used nebulization to treat the adhesion of leeches (blood-suckers) into the esophagus, which were commonly aspirated or swallowed due to their use in oral and facial diseases at that time and “... if the leech can be seen...take a hook or a small grasper, keep it tough and pull out" [4].

Later he described a technique to reach even more distal parts of the esophagus: “... take a hollow tube. Insert it into the patient’s throat and take a heated iron wire; insert it into this tube to reach the leech...” (Figure 3). The first application of hyperthermia on the esophagus!

Figure 3

Serefeddin Sabuncuoglu Textbook of Surgery 1460.

It was Andreas Vesalius (1514-1564), the father of Anatomy, who, after more than a millennium, challenged the anatomy as taught by Galen, which was based in part on the legacy of Hippocrates from dissections on animals. Vesalius’ De Humanis Corporis Fabrica published in 1543 [5], was the result of his extensive observations obtained from dissections on human cadavers (Figure 4). For the first time, a true anatomic description of the digestive tract became available.

The anatomy of the upper GI tract; esophagus and stomach, is described in detail and are beautifully illustrated in figures 14 and 15 of the fifth book. A remarkable feature of these illustrations are two nodular structures attached to the esophagus in the middle of it: “ ...glandular body (nodus lymphaticus) often attached to the esophagus where it rests upon the body of the fifth thoracic vertebra.” (Figure 4) [6].

Figure 4

Vesalius’ Anatomy of the Esophagus.

According to Vesalius, he thought that the glandules attached to the esophagus, make it’s inside wet and soak with a “humor” resembling saliva so that food because of dryness, will not have too much difficulty slipping into the stomach. However, when comparing these figures and the illustrations of the trachea and the bronchial bifurcationit is my interpretation that the glandules described along the mid-esophagus are nothing else than the subcarinal lymph nodes Other than this anatomical dissection, very few additional references are found in literature concerning surgery of the esophagus except for the occasional cervical esophagotomy for removal of a foreign body as described by Jean Baptiste Verduc in 1701 [7].

The world had to wait until the latter half of the 19^th century for Lister (antisepsis), Pasteur (asepsis) and of course for the invention of anesthesia by William Morton in the Ether dome of Massachusetts General Hospital in Boston on October 16^th 1846 to see surgery becoming safer and more secure. The location of the esophagus, deep in the chest alongside the vertebral column and the aorta behind the heart and the trachea, precluded surgical intervention until the advent of tracheal intubation and positive pressure ventilation. These innovations during the twenties and the thirties of the 20^th century permitted a thoracotomy to be safely performed. Major surgery i.e. esophagectomy took place in the two decades following the second world war. The most complete and detailed overview of the chronological sequence of events, including an inventory of every possible single author who contributed to the progress in esophageal surgery, comes from Richard Meade the thoracic surgical historian in his book “A History of Thoracic Surgery” published in 1961 [8].

In this chapter, a synopsis of the most relevant events that significantly contributed to the progress and today’s state of the art will be presented. See Table 1 for a Summary of milestones in modern esophageal surgery.