Oesophagectomy remains the gold standard for treatment of high-grade dysplasia in Barrett's oesophagus

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.

A Surgical View of Photodynamic Therapy in Oncology: A Review

Clinical photodynamic therapy (PDT) has existed for over 30 years, and its scientific basis has been known and investigated for well over 100 years. The scientific foundation of PDT is solid and its application to cancer treatment for many common neoplastic lesions has been the subject of a huge number of clinical trials and observational studies. Yet its acceptance by many clinicians has suffered from its absence from the undergraduate and/or postgraduate education curricula of surgeons, physicians, and oncologists. Surgeons in a variety of specialties many with years of experience who are familiar with PDT bear witness in many thousands of publications to its safety and efficacy as well as to the unique role that it can play in the treatment of cancer with its targeting precision, its lack of collateral damage to healthy structures surrounding the treated lesions, and its usage within minimal access therapy. PDT is closely related to the fluorescence phenomenon used in photodiagnosis. This review aspires both to inform and to present the clinical aspect of PDT as seen by a surgeon.

Early detection and prevention of pancreatic cancer: Is it really possible today?

Pancreatic cancer is the 4^th leading cause of cancer-related death in Western countries. Considering the low incidence of pancreatic cancer, population-based screening is not feasible. However, the existence of a group of individuals with an increased risk to develop pancreatic cancer has been well established. In particular, individuals suffering from a somatic or genetic condition associated with an increased relative risk of more than 5- to 10-fold seem to be suitable for enrollment in a surveillance program for prevention or early detection of pancreatic cancer. The aim of such a program is to reduce pancreatic cancer mortality through early or preemptive surgery. Considering the risk associated with pancreatic surgery, the concept of preemptive surgery cannot consist of a prophylactic removal of the pancreas in high-risk healthy individuals, but must instead aim at treating precancerous lesions such as intraductal papillary mucinous neoplasms or pancreatic intraepithelial neoplasms, or early cancer. Currently, results from clinical trials do not convincingly demonstrate the efficacy of this approach in terms of identification of precancerous lesions, nor do they define the outcome of the surgical treatment of these lesions. For this reason, surveillance programs for individuals at risk of pancreatic cancer are thus far generally limited to the setting of a clinical trial. However, the acquisition of a deeper understanding of this complex area, together with the increasing request for screening and treatment by individuals at risk, will usher pancreatologists into a new era of preemptive pancreatic surgery. Along with the growing demand to treat individuals with precancerous lesions, the need for low-risk investigation, low-morbidity operation and a minimally invasive approach becomes increasingly pressing. All of these considerations are reasons for preemptive pancreatic surgery programs to be undertaken in specialized centers only.

Minimally invasive esophagectomy for dysplastic Barrett's esophagus

A substantial portion of patients diagnosed preoperatively with high grade dysplasia (HGD) alone will have occult esophageal adenocarcinoma on analysis of the surgical specimen. Therefore, because of an increased risk of disease progression and malignancy, patients with HGD should be referred for esophagectomy promptly when endoscopic therapy has failed. The required extent of lymphadenectomy in this cohort of patients is unknown because of the variable incidence of submucosal cancer observed. Improvements in perioperative care, adoption of a minimally invasive surgical approach, and centralization of esophageal cancer services have substantially reduced the rates of mortality and morbidity associated with esophagectomy in recent years. Minimally invasive esophagectomy should be considered the treatment of choice in patients with dysplastic Barrett's esophagus that is refractory to endoscopic therapy or those at high risk of invasive cancer.

Management controversies in Barrett's oesophagus

The management of Barrett's oesophagus and associated neoplasia has evolved considerably in recent years. Modern endoscopic strategies including endoscopic resection and mucosal ablation can eradicate dysplastic Barrett's and prevent progression to invasive oesophageal cancer. However, several aspects of Barrett's management remain controversial including the stage in the disease process at which to intervene, and the choice of endoscopic or surgical therapy. A review of articles pertaining to the management of Barrett's oesophagus with or without associated neoplasia, was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, Embase and Cochrane databases were searched to identify literature relevant to eight pre-defined areas of clinical controversy. The following search terms were used: Barrett's oesophagus; dysplasia; intramucosal carcinoma; endotherapy; endoscopic resection; ablation; oesophagectomy. A significant body of evidence exists to support early endoscopic therapy for high-grade dysplasia (HGD). Although not supported by randomised controlled trial evidence, endoscopic therapy is now favoured ahead of oesophagectomy for most patients with HGD. Focal intramucosal (T1a) carcinomas can be managed effectively using endoscopic and surgical therapy, however surgery should be considered the first line therapy where there is submucosal invasion (T1b). Treatment of low grade dysplasia is not supported at present due to widespread over-reporting of the disease. The role of surveillance endoscopy in non-dysplastic Barrett's remains controversial.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

Esophagectomy for failed endoscopic therapy in patients with high-grade dysplasia or intramucosal carcinoma

Endoscopic therapy (ablation +/- endoscopic resection) for high-grade dysplasia and/or intramucosal carcinoma (IMC) of the esophagus has demonstrated promising results. However, there is a concern that a curable, local disease may progress to systemic disease with repeated endotherapy. We performed a retrospective review of patients who underwent esophagectomy after endotherapy at three tertiary care esophageal centers from 2006 to 2012. Our objective was to document the clinical and pathologic outcomes of patients who undergo esophagectomy after failed endotherapy. Fifteen patients underwent esophagectomy after a mean of 13 months and 4.1 sessions of endotherapy for progression of disease (53%), failure to clear disease (33%), or recurrence (13%). Initially, all had Barrett's, 73% had ≥3-cm segments, 93% had a nodule or ulcer, and 91% had multifocal disease upon presentation. High-grade dysplasia was present at index endoscopy in 80% and IMC in 33%, and some patients had both. Final pathology at esophagectomy was T0 (13%), T1a (60%), T1b (20%), and T2 (7%). Positive lymph nodes were found in 20%: one patient was T2N1 and two were T1bN1. Patients with T1b, T2, or N1 disease had more IMC on index endoscopy (75% vs. 18%) and more endotherapy sessions (median 6.5 vs. 3). There have been no recurrences a mean of 20 months after esophagectomy. Clinical outcomes were comparable to other series, but submucosal invasion (27%) and node-positive disease (20%) were encountered in some patients who initially presented with a locally curable disease and eventually required esophagectomy after failed endotherapy. An initial pathology of IMC or failure to clear disease after three treatments should raise concern for loco-regional progression and prompt earlier consideration of esophagectomy.

Advances in the clinical application of Raman spectroscopy for cancer diagnostics

Light interacts with tissue in a number of ways including, elastic and inelastic scattering, reflection and absorption, leading to fluorescence and phosphorescence. These interactions can be used to measure abnormal changes in tissue. Initial optical biopsy systems have potential to be used as an adjunct to current investigative techniques to improve the targeting of blind biopsy. Future prospects with molecular-specific techniques may enable objective optical detection providing a real-time, highly sensitive and specific measurement of the histological state of the tissue. Raman spectroscopy has the potential to identify markers associated with malignant change and could be used as diagnostic tool for the early detection of precancerous and cancerous lesions in vivo. The clinical requirements for an objective, non-invasive, real-time probe for the accurate and repeatable measurement of pathological state of the tissue are overwhelming. This paper discusses some of the recent advances in the field.

Directional distribution of neoplasia in Barrett's esophagus is not influenced by distance from the gastroesophageal junction

BACKGROUND

Accurate endoscopic detection and staging are critical for appropriate management of Barrett's esophagus (BE)-associated neoplasia. Prior investigation has demonstrated that the distribution of endoscopically detectable early neoplasia is not uniform but instead favors specific directional distributions within a short BE segment; however, it is unknown whether the directional distribution of neoplasia differs with increasing distance from the gastroesophageal junction, including in patients with long-segment BE.

OBJECTIVE

To identify whether directional distribution of BE-associated neoplasia is influenced by distance from the gastroesophageal junction.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

Patients with either short-segment or long-segment BE undergoing EMR.

INTERVENTION

EMR.

MAIN OUTCOME MEASUREMENTS

Directional distribution of BE-associated neoplasia stratified by distance from gastroesophageal junction.

RESULTS

EMR was performed on 60 lesions meeting study criteria during the specified time period. Pathology demonstrated low-grade dysplasia in 22% (13/60), high-grade dysplasia in 38% (23/60), intramucosal (T1a) adenocarcinoma in 23% (14/60), and invasive (≥ T1b) adenocarcinoma in 17% (10/60). Directional distribution of lesions was not uniform (P < .001), with 62% of lesions (37/60) located between the 1 o'clock and 5 o'clock positions. When circular statistics methodology was used, there was no difference in the directional distribution of neoplastic lesions located within 3 cm of the gastroesophageal junction compared with ≥ 3 cm from the gastroesophageal junction.

LIMITATIONS

Single-center study may limit external validity.

CONCLUSION

The directional distribution of neoplastic foci within a BE segment is not influenced by distance of the lesion from the gastroesophageal junction. Mucosa between the 1 o'clock and 5 o'clock locations merits careful attention and endoscopic inspection in individuals with both short-segment BE and long-segment BE.

Outcomes in patients who have failed endoscopic therapy for dysplastic Barrett's metaplasia or early esophageal cancer

BACKGROUND

Endoscopic therapy (ablation ± mucosal resection) for esophageal high-grade dysplasia (HGD) or intramucosal carcinoma has demonstrated promising results. Little is known about patients who have persistent or progressive disease despite endotherapy. We compared patients who had successful eradication of their disease with those in whom endotherapy failed to try to identify factors predictive of failure and outcomes after salvage therapy.

METHODS

We performed a single-institution retrospective review of patients treated with endotherapy from 2007 to 2012.

RESULTS

Thirty-eight patients underwent endotherapy: 28 had successful eradication of their disease and endotherapy failed in 10 patients. Patients in whom endotherapy failed were more likely to have high-grade dysplasia (HGD) on initial endoscopy, nodules or ulcers, multifocal dysplasia, and persistent nondysplastic Barrett's metaplasia. Patients in whom endotherapy failed also underwent significantly more endotherapy sessions. Seven patients had persistent dysplasia or progression to cancer, and 3 patients had complete eradication of HGD but presented with intramucosal carcinoma an average of 15 months after eradication. The 10 patients in whom endotherapy failed underwent salvage therapy with esophagectomy (7 patients), definitive chemoradiotherapy (1 patient), and endotherapy (2 patients). Patients treated with esophagectomy were disease free at a mean of 25 months postoperatively.

CONCLUSIONS

HGD on initial endoscopy, multifocal dysplasia, mucosal abnormalities, and failure to eradicate nondysplastic Barrett's metaplasia were associated with failure of endotherapy. Patients with these characteristics should be considered at higher risk for treatment failure, and earlier consideration should be given to esophagectomy if there is persistent, progressive, or recurrent neoplasia. Clinical outcomes are good, even after salvage therapy. Continued endoscopic surveillance is mandatory after successful endotherapy because of the risk of recurrent disease.

Expert pathology review and endoscopic mucosal resection alters the diagnosis of patients referred to undergo therapy for Barrett's esophagus

BACKGROUND

Endoscopic therapy has emerged as an alternative to surgical esophagectomy for the management of Barrett's esophagus (BE)-associated neoplasia. Accurate pretreatment staging is essential to ensure an appropriate choice of therapy and optimal long-term outcomes. This study aimed to assess the frequency with which expert histopathologic review of biopsies combined with endoscopic mucosal resection (EMR) would alter the pretreatment diagnosis of BE-associated neoplasia.

METHODS

Patients referred to the Vanderbilt Barrett's Esophagus Endoscopic Treatment Program (V-BEET) were retrospectively identified. Demographic, histopathologic, and endoscopic data were extracted from the medical record.

RESULTS

For this study, 29 subjects referred for endoscopic staging of BE fulfilled the entry criteria. The referral diagnosis was low-grade dysplasia (LGD) in 3 % (1/29), high-grade dysplasia (HGD) in 62 % (18/29), intramucosal adenocarcinoma (T1a) adenocarcinoma in 17 % (5/29), and invasive adenocarcinoma in 17 % (5/29) of the subjects. Expert histopathologic review of available referral biopsy specimens altered the diagnosis in 33 % (5/15) of the cases. Further diagnostic staging with EMR showed BE without dysplasia in 10 % (3/29), LGD in 14 % (4/29), HGD in 34 % (10/29), T1a adenocarcinoma in 28 % (8/29), and invasive adenocarcinoma in 14 % (4/29) of the patients. The combination of expert histopathologic review and EMR altered the initial diagnosis for 55 % (16/29) of the subjects, with 56 % (9/16) upstaged to more advanced disease and 44 % (7/16) downstaged to less advanced disease.

CONCLUSIONS

The practice of combined expert histopathologic review and EMR alters the pretreatment diagnosis for the majority of patients with BE-associated neoplasia. Caution is advised for those embarking on endoscopic or surgical treatment for BE-associated neoplasia in the absence of these staging methods.

The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review

OBJECTIVES

Endoscopic eradication therapy is used to treat mucosal neoplasms in Barrett's esophagus, but cannot cure cancers that have metastasized to lymph nodes. The risk of such metastases has been proposed as a reason to consider esophagectomy rather than endoscopic therapy for esophageal mucosal neoplasia. The objective of our study was to determine the frequency of lymph-node metastases in patients with high-grade dysplasia (HGD) and intramucosal carcinoma in Barrett's esophagus.

METHODS

We performed a systematic review using the PRISMA guidelines to identify studies that included patients who had esophagectomy for HGD or intramucosal carcinoma in Barrett's esophagus, and that reported final pathology results after examination of esophagectomy specimens.

RESULTS

We identified 70 relevant reports that included 1,874 patients who had esophagectomy performed for HGD or intramucosal carcinoma in Barrett's esophagus. Lymph-node metastases were found in 26 patients (1.39 % , 95 % CI 0.86 – 1.92). No metastases were found in the 524 patients who had a final pathology diagnosis of HGD, whereas 26 (1.93 % , 95 % CI 1.19 – 2.66 %) of the 1,350 patients with a final pathology diagnosis of intramucosal carcinoma had positive lymph nodes.

CONCLUSIONS

The risk of unexpected lymph-node metastases for patients with mucosal neoplasms in Barrett's esophagus is in the range of 1 – 2 %. Esophagectomy has a mortality rate that often exceeds 2 %, with substantial morbidity and no guarantee of curing metastatic disease. Therefore, the risk of lymph node metastases alone does not warrant the choice of esophagectomy over endoscopic therapy for HGD and intramucosal carcinoma in Barrett's esophagus.

An analysis of esophagectomy and other techniques in the management of high-grade dysplasia of Barrett's esophagus

Barrett's esophageal (BE) metaplasia is a premalignant condition of the distal esophagus that develops as a consequence of gastroesophageal reflux disease. The progression to carcinogenesis results from progressive dysplastic changes of the metaplastic epithelium through low-grade and then high-grade dysplasia (HGD) to eventually adenocarcinoma of the esophagus. The management of HGD is controversial with proponents for each of the three major management strategies: endoscopic surveillance, endoscopic ablative therapies, and esophagectomy. The aim of the study was to define and discuss the various management strategies of HGD arising from BE metaplasia. There is a paucity of randomized controlled data from which to draw definitive conclusions. All strategies for the management of HGD are reasonable options and are complimentary. BE with HGD is a malignant lesion. A multidisciplinary approach individualizing therapy should be undertaken when possible. Esophageal resection should be reserved for otherwise healthy patients. Endoscopic techniques are viable alternatives to surgery.

Management of Barrett esophagus with high-grade dysplasia

High-grade dysplasia in Barrett esophagus is a marker for future development of cancer and for the existence of synchronous cancer. A significant problem in management is intraobserver and interobserver variation in the diagnosis of high-grade dysplasia in Barrett esophagus, the natural history of which is poorly understood; thus, treatment decisions are problematic. The ability to preserve the esophagus with endoscopic mucosal ablation or resection and reduce morbidity of treatment has made endoscopic treatment the mainstay of therapy. Esophagectomy is reserved for treatment failures and for high-grade dysplasia not amenable to less aggressive therapies. This article outlines the data supporting current management strategies.

Barrett's esophagus with high-grade dysplasia: Focus on current treatment options

High-grade dysplasia (HGD) in Barrett’s esophagus (BE) is the critical step before invasive esophageal adenocarcinoma. Although its natural history remains unclear, an aggressive therapeutic approach is usually indicated. Esophagectomy represents the only treatment able to reliably eradicate the neoplastic epithelium. In healthy patients with reasonable life expectancy, vagal-sparing esophagectomy, with associated low mortality and low early and late postoperative morbidity, is considered the treatment of choice for BE with HGD. Patients unfit for surgery should be managed in a less aggressive manner, using endoscopic ablation or endoscopic mucosal resection of the entire BE segment, followed by lifelong surveillance. Patients eligible for surgery who present with a long BE segment, multifocal dysplastic lesions, severe reflux symptoms, a large fixed hiatal hernia or dysphagia comprise a challenging group with regard to the appropriate treatment, either surgical or endoscopic.

Update on staging and surgical treatment options for esophageal cancer

INTRODUCTION

Esophageal cancer remains a challenging clinical problem, with overall long-term survivorship consistently at a level of approximately 30%. The incidence of esophageal cancer is increasing worldwide, with the most dramatic increase being seen with respect to esophageal adenocarcinoma.

DISCUSSION

Pretreatment staging accuracy has improved with the utilization of CT and PET scans, as well as endoscopic ultrasound and endoscopic mucosal resection. In an increasing percentage of patients, endoscopic techniques are being utilized in selected patients for the treatment of high-grade dysplasia in Barrett's and intramucosal cancer. Surgery remains the treatment of choice in all appropriate patients with invasive and locoregional esophageal cancer, although multimodality therapy is now used in most patients with stage II or stage III disease.

CONCLUSION

Outcomes for esophagectomy have been dominated by concerns regarding high mortality and morbidity; however, mortality rates associated with esophageal resection have dramatically decreased, especially in high-volume specialty centers. This manuscript highlights some of the evolutionary issues associated with staging and endoscopic and surgical treatments of Barrett's and esophageal cancer.

A UK-based cost-utility analysis of radiofrequency ablation or oesophagectomy for the management of high-grade dysplasia in Barrett's oesophagus

BACKGROUND

In the UK, oesophagectomy is the current recommendation for patients with persistent high-grade dysplasia in Barrett's oesophagus. Radiofrequency ablation is an alternative new technology with promising early trial results.

AIM

To undertake a cost-utility analysis comparing these two strategies.

METHODS

We constructed a Markov model to simulate the natural history of a cohort of patients with high-grade dysplasia in Barrett's oesophagus undergoing one of two treatment options: (i) oesophagectomy or (ii) radiofrequency ablation followed by endoscopic surveillance with oesophagectomy for high-grade dysplasia recurrence or persistence.

RESULTS

In the base case analysis, radiofrequency ablation dominated as it generated 0.4 extra quality of life years at a cost saving of £1902. For oesophagectomy to be the most cost-effective option, it required a radiofrequency ablation treatment failure rate (high-grade dysplasia persistence or progression to cancer) of >44%, or an annual risk of high-grade dysplasia recurrence or progression to cancer in the ablated oesophagus of >15% per annum. There was an 85% probability that radiofrequency ablation remained cost-effective at the NICE willingness to pay threshold range of £20 000-30 000.

CONCLUSION

Radiofrequency ablation is likely to be a cost-effective option for high-grade dysplasia in Barrett's oesophagus in the UK.

Review of open and minimal access approaches to oesophagectomy for cancer

BACKGROUND

Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit.

METHODS

Demographic and clinical data were entered into a prospective database. MIO was thoracoscopic-laparoscopic-cervical anastomosis, hybrid surgery was thoracoscopic-laparotomy or laparoscopic gastric mobilization-thoracotomy, and open resections were left thoracoabdominal (LTA), Ivor Lewis (IL) or transhiatal oesophagectomy (THO).

RESULTS

There were 118 resections for carcinoma (23 squamous cell carcinoma, 95 adenocarcinoma) and three for high-grade dysplasia. MIO took longer than open surgery (median 6·5 h versus 4·8 h for THO, 4·7 h for IL and LTA). MIO required less epidural time (P < 0·001 versus IL and LTA, P = 0·009 versus thorascopic hybrid, P = 0·014 versus laparoscopic IL). Despite a shorter duration of single-lung ventilation with MIO compared with IL and LTA (median 90 versus 150 min; P = 0·013), respiratory complication rates and duration of hospital stay were similar. There were seven anastomotic leaks after MIO, four after hybrid procedures and one following open surgery. Mortality rates were 2, 6 and 2 per cent respectively. Lymph node harvests were similar between all groups, as were rates of complete (R0) resection in patients with locally advanced tumours.

CONCLUSION

MIO is technically feasible. It does not reduce pulmonary complications or length of stay. Oncological outcomes appear equivalent.

Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy

BACKGROUND

Recently, several new endoscopic treatments have been used to treat patients with Barrett's esophagus with high grade dysplasia. This systematic review aimed to determine the safety and effectiveness of these treatments compared with esophagectomy.

METHODS

A comprehensive literature search was undertaken to identify studies of endoscopic treatments for Barrett's esophagus or early stage esophageal cancer. Information from the selected studies was extracted by two independent reviewers. Study quality was assessed and information was tabulated to identify trends or patterns. Results were pooled across studies for each outcome. Safety (occurrence of adverse events) and effectiveness (complete eradication of dysplasia) were compared across different treatments.

RESULTS

The 101 studies that met the selection criteria included 8 endoscopic techniques and esophagectomy; only 12 were comparative studies. The quality of evidence was generally low. Methods and outcomes were inconsistently reported. Protocols, outcomes measured, follow-up times and numbers of treatment sessions varied, making it difficult to calculate pooled estimates.The surgical mortality rate was 1.2%, compared to 0.04% in 2831 patients treated endoscopically (1 death). Adverse events were more severe and frequent with esophagectomy, and included anastomotic leaks (9.4%), wound infections (4.1%) and pulmonary complications (4.1%). Four patients (0.1%) treated endoscopically experienced bleeding requiring transfusions. The stricture rate with esophagectomy (5.3%) was lower than with porfimer sodium photodynamic therapy (18.5%), but higher than aminolevulinic acid (ALA) 60 mg/kg PDT (1.4%). Dysphagia and odynophagia varied in frequency across modalities, with the highest rates reported for multipolar electrocoagulation (MPEC). Photosensitivity, an adverse event that occurs only with photodynamic therapy, was experienced by 26.4% of patients who received porfimer sodium.Some radiofrequency ablation (RFA) or argon plasma coagulation (APC) studies (used in multiple sessions) reported rates of almost 100% for complete eradication of dysplasia. But the study methods and findings were not adequately described. The other studies of endoscopic treatments reported similarly high rates of complete eradication.

CONCLUSIONS

Endoscopic treatments offer safe and effective alternatives to esophagectomy for patients with Barrett's esophagus and high grade dysplasia. Unfortunately, shortcomings in the published studies make it impossible to determine the comparative effectiveness of each of the endoscopic treatments.

Trends in the management of esophageal carcinoma based on provider volume: treatment practices of 618 esophageal surgeons

Controversy exists regarding optimal treatment practices for esophageal cancer. Esophagectomy has received focus as one of the index procedures for both hospital and surgical quality despite a relative paucity of controlled trials to define best practices. A survey was created to determine the degree of heterogeneity in the treatment of esophageal cancer among a diverse group of surgeons and to use high-volume (HV) (>/=15 cases/year) and low-volume (LV) (<15 cases/year) designations to discern specific differences in the management of esophageal cancer from the surgeon's perspective. Based on society rosters, surgeons (n = 4000) in the USA and 15 countries were contacted via mail and queried regarding their treatment practices for esophageal cancer using a 50-item survey instrument addressing demographics, utilization of neoadjuvant chemoradiotherapy, and choice of surgical approach for esophageal resection and palliation. There were 618 esophageal surgeons among respondents (n = 1447), of which 77 (12.5%) were considered HV. The majority of HV surgeons (87%) practiced in an academic setting and had cardiothoracic training, while most LV surgeons were general surgeons in private practice (52.3%). Both HV and LV surgeons favored the hand-sewn cervical anastomosis and the stomach conduit. Minimally invasive esophagectomy is performed more frequently by HV surgeons when compared with LV surgeons (P = 0.045). Most HV surgeons use neoadjuvant therapy for patients with nodal involvement, while LV surgeons are more likely to leave the decision to the oncologist. With a few notable exceptions, substantial heterogeneity exists among surgeons' management strategies for esophageal cancer, particularly when grouped and analyzed by case volume. These results highlight the need for controlled trials to determine best practices in the treatment of this complex patient population.

Preemptive surgery for premalignant foregut lesions

INTRODUCTION

Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery).

METHODS

A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions.

RESULTS AND DISCUSSION

In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated.

CONCLUSIONS

Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.

Mucosectomy for high‐grade dysplasia in Barrett's esophagus

Reports on the natural history of high-grade dysplasia (HGD) are sometimes contradictory, but suggest that 10-30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non-surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non-operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.

The Society of Thoracic Surgeons practice guideline series: guidelines for the management of Barrett's esophagus with high-grade dysplasia

The management of Barrett's esophagus with high-grade dysplasia is controversial. The standard of care has traditionally been esophagectomy. However, a number of treatment options aimed at esophageal preservation are increasingly being utilized by many centers. These esophageal-sparing approaches include endoscopic surveillance, mucosal ablation, and endoscopic mucosal resection. In this guideline we review the best evidence supporting these commonly used strategies for high-grade dysplasia to better define management and guide future investigation.

Patient predictors of histopathologic response after photodynamic therapy of Barrett's esophagus with high-grade dysplasia or intramucosal carcinoma

BACKGROUND

Photodynamic therapy (PDT) has been used extensively for endoscopic ablation of Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal carcinoma.

OBJECTIVE

To identify patient variables that influence the likelihood of response to PDT.

DESIGN

A retrospective cohort study.

SETTING

Tertiary-referral center.

PATIENTS

A total of 116 patients with Barrett's esophagus and with HGD, intramucosal carcinoma, or T1 cancer.

INTERVENTIONS

PDT with porfimer sodium.

MAIN OUTCOME MEASUREMENTS

(1) Ablation of HGD and/or intramucosal carcinoma and (2) eradication of all Barrett's epithelium.

RESULTS

Of the patients, 51% underwent treatment for HGD and 49% of patients had intramucosal carcinoma or T1 cancer. At 12-month follow-up, ablation of HGD and/or cancer was observed in 70% of patients, and ablation of all Barrett's epithelium was observed in 39%. In multivariate analysis, the pretreatment length of Barrett's esophagus was inversely correlated with successful ablation of all Barrett's epithelium. Patients with Barrett's esophagus length more than 3 cm were less likely to experience complete ablation compared with patients with Barrett's esophagus length 3 cm or less (odds ratio [OR] 0.15 [95% CI, 0.04-0.50]). Patients with intramucosal carcinoma were not significantly less likely to experience elimination of HGD and/or cancer (OR 0.77 [95% CI, 0.30-2.00]) or ablation of all Barrett's epithelium (OR 0.82 [95% CI, 0.32-2.07]) compared with patients with HGD alone.

LIMITATIONS

Retrospective study, limited sample size without a control group for comparison.

CONCLUSIONS

PDT of Barrett's esophagus with HGD, intramucosal carcinoma, or T1 cancer can result in ablation of dysplasia and/or eradication of all Barrett's epithelium. Factors associated with the likelihood of response include length of Barrett's esophagus. The presence of intramucosal carcinoma or T1 cancer was not associated with higher likelihood of treatment failure.

Treatment of Barrett's esophagus with high-grade dysplasia or cancer: predictors of surgical versus endoscopic therapy

BACKGROUND & AIMS

Patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma are at risk of progression to invasive carcinoma. Both esophagectomy and endoscopic ablation are treatment options. The aim of this study was to identify predictors of surgical versus endoscopic therapy at a tertiary center.

METHODS

An institutional database identified patients with Barrett's esophagus between 2003 and 2007. Demographic data and International Classification of Diseases-9th revision codes for esophagectomy, endoscopic ablation, as well as selected medical comorbidities were retrieved. Individual endoscopy, surgical, and pathology reports were reviewed.

RESULTS

Among 2107 individuals with Barrett's esophagus, 79 underwent esophagectomy and 80 underwent endoscopic ablation. The mean age was 63.1 +/- 10.6 years in the surgical group and 69.7 +/- 9.4 years in the ablation group (P < .0001). Among high-grade dysplasia/intramucosal carcinoma patients, 9 of 76 (12%) first seen by a gastroenterologist underwent esophagectomy, whereas 18 of 21 (86%) first seen by a surgeon underwent esophagectomy. In a logistic regression model, factors associated independently with esophagectomy were as follows: patient age of 60 or younger (odds ratio [OR], 4.95; 95% confidence interval [CI], 1.65-14.9), cancer stage T1sm or greater (OR, 16.0; 95% CI, 5.60-45.6), and initial consultation performed by a surgeon (vs gastroenterologist) (OR, 35.1; 95% CI, 9.58-129).

CONCLUSIONS

Patient age and cancer stage predict treatment modality for Barrett's esophagus with neoplasia. Treatment choice is influenced further by whether the initial evaluation is performed by a gastroenterologist or a surgeon.

Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett's esophagus overestimated?

BACKGROUND & AIMS

Recent studies have claimed long neoplasia-free survival rates with endoscopic mucosal resection of high-grade dysplasia (HGD) in Barrett's esophagus (BE). However, reports have contended that approximately 40% of patients who have esophagectomy for HGD have occult invasive cancer. The aim of this study was to use explicit criteria to determine the true prevalence of invasive adenocarcinoma in reports of patients who had esophagectomy for HGD in BE.

METHODS

Studies reporting rates of esophageal cancer in patients who underwent esophagectomy for HGD in BE were gathered using MEDLINE and PUBMED. We defined invasive esophageal adenocarcinoma (IEAC) as tumor with submucosal invasion or beyond. Intramucosal carcinoma (IMC) was not considered IEAC.

RESULTS

Twenty-three articles were selected for analysis. Most investigators reported rates of invasive cancer in the esophagectomy specimen, and the pooled average was 39.9% among the 441 patients who underwent an esophagectomy for HGD. Reported rates varied from 0% to 73%. A total of 267 patients had American Joint Committee on Cancer stage 0 postoperatively, 132 patients had stage I, 23 patients had stage IIa, 10 patients had stage IIb, and 9 patients had stage III. Fourteen studies provided differentiation between intramucosal and submucosal invasion. Among 213 patients, only 12.7% had IEAC, whereas 87.3% had HGD or IMC. The IEAC rate of 11% among patients with visible lesions is greater than the rate of 3% among patients with no visible lesion.

CONCLUSIONS

By using strict pathologic definitions of invasive disease, the present study indicates the true prevalence of IEAC in BE and HGD may have been overestimated significantly. Separating IMC from IEAC is clinically relevant because endoscopic techniques potentially may treat IMC.

Esophagectomy for high grade dysplasia is safe, curative, and results in good alimentary outcome

BACKGROUND

The increasing adoption of endoscopic therapies and expectant surveillance for patients with high grade dysplasia (HGD) in Barrett's esophagus has created considerable controversy regarding the ideal treatment choice. Confusion may be due, in part, to a limited understanding of the outcomes associated with surgical resection for HGD and extrapolation of data derived from patients undergoing an esophagectomy for invasive cancer. The purpose of our study was to document the perioperative and symptomatic outcomes and long-term survival after esophagectomy for HGD of the esophagus.

MATERIAL AND METHODS

The study population consisted of 38 patients who underwent esophagectomy for biopsy-proven HGD between 10/1999 and 6/2005. Three patients were excluded from analysis due to obvious tumor on upper endoscopy. Patients were evaluated regarding ten different foregut symptoms and administered a ten-question appraisal of eating and bowel habits. Outcome measures included postoperative morbidity and mortality, the prevalence of invasive cancer in the esophagectomy specimens, symptomatic and functional alimentary results, patient satisfaction, and long-term survival. Median follow-up was 32 months (range, 7-83).

RESULTS

Thirty-day postoperative and in-hospital mortality was zero. Complications occurred in 37% (13/35), and median length of stay was 10 days. Occult adenocarcinoma was found in 29% (10/35) of surgical specimens (intramucosal in four; submucosal in five; and intramuscular in one with a single positive lymph node.) Patients consumed a median of three meals per day, most (76%, 26/34) had no dietary restrictions, and two-thirds (23/34) considered their eating pattern to be normal or only mildly impacted. Meal size, however, was reported to be smaller in the majority (79%, 27/34) of patients. Median body mass index (BMI) decreased slightly after surgery (28.6 vs 26.6, p>0.05), but no patient's BMI went below normal. The number of bowel movements/day was unchanged or less in a majority (82%) of patients after surgery. Fifteen of 34 (44%) patients reported loose bowel movements, which occurred less often than once per week in 10 of the 15. One patient had symptoms of dumping. Mean symptom severity scores improved for all symptoms except dysphagia and choking. Four patients developed foregut symptoms that occurred daily. Most patients (82%) required at least one postoperative dilation for dysphagia. Almost all (97%) patients were satisfied. Disease-free survival was 100%, and overall survival was 97% (34/35) at a median of 32 months.

CONCLUSION

Esophagectomy is an effective and curative treatment for HGD and can be performed with no mortality, acceptable morbidity, and good alimentary outcome. These data provide a gold standard for comparison to alternative therapies.

Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett's esophagus

BACKGROUND & AIMS

Photodynamic therapy (PDT) for high-grade dysplasia (HGD) in Barrett's esophagus is a Food and Drug Administration-approved alternative to esophagectomy. Critical information regarding overall survival of patients followed up long-term after these therapies is lacking. Our aim was to compare the long-term survival of patients treated with PDT with patients treated with esophagectomy.

METHODS

We reviewed records of patients with HGD seen at our institution between 1994 and 2004. PDT was performed 48 hours following the intravenous administration of a photosensitizer using light at 630 nm. Esophagectomy was performed by either transhiatal or transthoracic approaches by experienced surgeons. We excluded all patients with evidence of cancer on biopsy specimens. Vital status and death date information was queried using an institutionally approved Internet research and location service. Statistical analysis was performed using Kaplan-Meier curves and Cox proportional hazards ratios.

RESULTS

A total of 199 patients were identified. A total of 129 patients (65%) were treated with PDT and 70 (35%) with esophagectomy. Overall mortality in the PDT group was 9% (11/129) and in the surgery group was 8.5% (6/70) over a median follow-up period of 59 +/- 2.7 months for the PDT group and 61 +/- 5.8 months for the surgery group. Overall survival was similar between the 2 groups (Wilcoxon test = 0.0924; P = .76). Treatment modality was not a significant predictor of mortality on multivariate analysis.

CONCLUSIONS

Overall mortality and long-term survival in patients with HGD treated with PDT appears to be comparable to that of patients treated with esophagectomy.

Barrett's esophagus and adenocarcinoma of the gastroesophageal junction: a pathologic perspective

Barrett's esophagus is defined clinically by the presence of endoscopically evident columnar mucosa in the distal esophagus with histopathologic confirmation of the presence of intestinal-type epithelium. The etiology of Barrett's esophagus is understood poorly, but chronic gastroesophageal reflux disease is considered a major contributing factor. Barrett's esophagus is associated with the development of adenocarcinoma of the gastroesophageal junction. It is believed that the development of a Barrett-type mucosa with intestinal goblet-type cells is due to an altered process of differentiation of pluripotent epithelial stem cells in response to the local injury and repair process. The potential identification and isolation of markers for screening purposes and possibly prognostic information are areas of considerable clinical and scientific interest.