Ablative mucosectomy is the procedure of choice to prevent Barrett's cancer

Surgical Management of Barrett's-Related Neoplasia

The management of Barrett's-related neoplasia has benefited from advances in endoscopic assessment, resection, and ablation, along with improved pathologic and radiographic staging. The development of specialized, high-volume esophageal multidisciplinary teams, with improvements in patient selection, preparation, perioperative care, minimally invasive operative approaches, and enhanced recovery after surgery programs, has contributed to improved outcomes for patients undergoing esophagectomy for Barrett's-related neoplasia.

Esophagectomy for Superficial Esophageal Neoplasia

Endoscopic therapies have become the standard of care for most cases of Barrett's esophagus with high-grade dysplasia or intramucosal adenocarcinoma. Despite a rapid and dramatic evolution in treatment paradigms, esophagectomy continues to occupy a place in the therapeutic armamentarium for superficial esophageal neoplasia. The managing physician must remain cognizant of the limitations of endoscopic approaches and consider surgical resection when they are exceeded. Esophagectomy, performed at experienced centers for appropriately selected patients with early-stage disease can be undertaken with the expectation of cure as well as low mortality, acceptable morbidity, and good long-term quality of life.

Surgical Management of Barrett's Esophagus

Patients with gastroesophageal reflux disease and Barrett's esophagus can be a management challenge for the treating physician or surgeon. The goals of therapy include relief of reflux symptoms, induction of histologic regression, and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma. Antireflux surgery is effective at achieving these end points, although ongoing follow-up and endoscopic surveillance are essential. In cases of dysplasia or early esophageal neoplasia associated with Barrett's esophagus, endoscopic resection and ablation have supplanted esophagectomy as the standard of care in most cases. Esophageal resection continues to have a role, however, in a minority of appropriately selected candidates.

Endoscopic therapies for Barrett's neoplasia

The standard of care for treatment of Barrett's esophagus (BE) with early esophageal neoplasia, including high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC), has undergone a revolution over the past several years. With the introduction and popularization of endoscopic ablative technologies, along with the refinement of endoscopic mucosal resection (EMR) techniques, the majority of cases of early neoplasia in the setting of BE now are managed by endoscopic approaches. As a result, many patients who previously would have been referred for esophagectomy now may be spared from this major surgical procedure with its inherent morbidity, potential for mortality, and negative impact on long-term gastrointestinal function. The esophageal surgeon must be knowledgeable about the indications for such endoscopic therapies, as well as their limitations and potential pitfalls, so as to apply them in the appropriate clinical scenarios.

New endoscopic and surgical treatment options for early esophageal adenocarcinoma

Although the outcome for advanced stage esophageal cancer is poor, the early detection and treatment of early stage disease is usually associated with a much better outcome. Until recently, esophagectomy has been the treatment of choice in fit patients. However, morbidity is significant, and this has encouraged the development of newer endoscopic treatments that preserve the esophagus. These techniques include ablation and mucosal resection. Promising results are described, and endoscopic methods might provide a reasonable alternative for the treatment of early esophageal cancer. However, follow-up remains short and endoscopic treatment does not deal with potential lymphatic spread. Hence, careful selection is required. Minimally invasive techniques for esophageal resection have also been shown to be feasible, although there is only limited evidence that they reduce postoperative morbidity. Better data are still required to demonstrate improved outcomes from endoscopic treatment and minimally invasive esophagectomy.

Endoscopic Mucosal Resection and Vagal-Sparing Esophagectomy for High-Grade Dysplasia and Adenocarcinoma of the Esophagus

Once a rare tumor, adenocarcinoma of the esophagus is currently the cancer with the fastest rising incidence in America. In addition to the increasing prevalence of the disease, surveillance programs for patients with Barrett's have led to the identification of increasing numbers of patients with high-grade dysplasia or early-stage esophageal adenocarcinomas. Although traditional esophagectomy is curative in the majority of these patients, associated morbidity and mortality remains a hurdle for patient acceptance of the procedure. New endoscopic and surgical therapies offer the potential of decreased morbidity, but do not include a lymphadenectomy, and consequently, are not appropriate in patients that have a significant risk of lymph node metastases. Endoscopic mucosal resection allows precise determination of the depth of tumor invasion and facilitates accurate local staging of early esophageal cancers. A vagal-sparing esophagectomy accomplishes the goal of removing the diseased esophagus while minimizing the physiologic impact of an esophagectomy in patients with early-stage esophageal cancer.

Barrett's oesophagus: the new endoscopic modalities have a future

Barrett's oesophagus is defined as the replacement of squamous oesophageal epithelium by intestinal metaplasia in the distal oesophagus. It is a fairly frequent complication of gastro-oesophageal reflux disease (GORD): 5-10% of patients with GORD suffer from Barrett's oesophagus. GORD is essential for the development of Barrett's oesophagus.1 Intestinal metaplasia is a premalignant lesion that may further develop into dysplasia and lead to adenocarcinoma of the oesophagus. The latter now accounts for almost 50% of oesophageal cancer cases in western countries, and the largest increase in its incidence was recorded during the past two decades. Patients with Barrett's oesophagus have a 2-25% risk of developing mild to severe dysplasia and a 2-5% risk of having adenocarcinoma: 30-150 times higher than the risk in the general population. Forty to fifty per cent of Barrett's oesophagus patients with severe dysplasia would present adenocarcinoma within 5 years.

Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma

BACKGROUND

Endoscopic ablation and vagal-sparing esophagectomy offer the potential for reduced morbidity in patients with high-grade dysplasia or early esophageal adenocarcinoma, but neither includes a lymphadenectomy. Although adequate for intramucosal tumors, both are potentially inadequate for patients with submucosal tumor invasion given the high prevalence of nodal metastases with these lesions. Currently there is no test including endoscopic ultrasound that can accurately determine whether a small tumor is confined to the mucosa or has penetrated into the submucosa. The aim of this study was to compare the pathologic depth of invasion by endoscopic mucosal resection with findings and outcome after surgical resection to assess the accuracy and reliability of endoscopic mucosal resection for staging early esophageal adenocarcinoma.

METHODS

From 2001 to 2003, 7 patients presented with small, endoscopically visible adenocarcinomas. All underwent endoscopic mucosal resection followed by surgical resection.

RESULTS

Analysis of the resected specimens confirmed that the endoscopic mucosal resection had accurately determined the depth of tumor invasion in all patients, and had completely excised the lesion in all but 1 patient (86%). Lymph node dissection was included as part of the resection in 2 patients with submucosal invasion by endoscopic mucosal resection, and a vagal-sparing esophagectomy was used in the 5 patients with only intramucosal tumors. All patients are alive and disease-free at a median follow-up of 7 months.

CONCLUSIONS

Endoscopic mucosal resection accurately determines the depth of tumor invasion, and should be used as a staging procedure in patients with early esophageal cancer when therapies that do not include a lymphadenectomy are considered.

Sclerosing cholangitis

PURPOSE OF REVIEW

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by strictures of the biliary tree. It is closely associated with inflammatory bowel disease, particularly ulcerative colitis, although the precise etiology remains unknown. The prevalence of PSC, with its attendant medical burdens, appears to be higher than previously estimated; consequently, increasing numbers of patients are being diagnosed and treated in secondary care.

RECENT FINDINGS

Research into etiopathogenesis, epidemiology, small-duct PSC, and associations with cholangiocarcinoma and colorectal carcinoma are discussed, along with medical therapy and transplantation.

SUMMARY

Small-duct PSC is a distinct clinical entity associated with a benign course and minimal risk of cholangiocarcinoma compared with large-duct PSC. The incidence of gall bladder cancer is increased in patients with PSC, and yearly ultrasonographic screening, with cholecystectomy for gall bladder polyps, is recommended. Recent pilot studies have suggested that high-dose ursodeoxycholic acid (20 mg/kg body weight) may slow liver fibrosis and cholangiographic appearances. Importantly, ursodeoxycholic acid has also been shown to reduce the incidence of colonic dysplasia and colorectal cancer in patients with PSC and ulcerative colitis. Endoscopic therapy, usually balloon dilatation, is effective for benign dominant strictures that are causing jaundice. Liver transplant remains the only treatment in end-stage disease; however, posttransplant recurrence of PSC occurs in as many as one third of patients. Colorectal cancer develops posttransplant in 5 to 10% of those with inflammatory bowel disease. Annual screening colonoscopy is recommended for all patients with PSC with coexisting inflammatory bowel disease.