Endoscopic Mucosal Resection Versus Esophagectomy for Intramucosal Adenocarcinoma in the Setting of Barrett’s Esophagus

Chao Li, Denise Tami Yamashita, Harry Henteleff, Drew Bethune, James Ellsmere. Dalhousie University

INTRODUCTION: Esophagectomy has classically been the standard of care for patients with intramucosal adenocarcinoma (IMC) in the setting of Barrett’s esophagus. It is, however, associated with significant postoperative morbidity and mortality. Endoscopic mucosal resection (EMR) offers the potential for a minimally invasive approach with lesser morbidity. The purpose of this study is to investigate the transition of therapy from esophagectomy to EMR for IMC with respects to successful eradication rates, number of EMRs required, post-operative morbidity, and long-term survival.

METHODS: Patients with a diagnosis of IMC from 2005 to 2013 at a single-center were identified retrospectively. Beginning in 2009, preferred initial therapy for IMC transitioned from esophagectomy to EMR. Esophagectomy was performed either through a transthoracic Ivor-Lewis or a transhiatal technique. EMR was repeated until resolution of IMC on pathological specimen or progression of disease. Continuous data is expressed as mean (SD) and analyzed using Student’s t-test. Categorical data is presented as number (%) and analyzed using the chi-squared test.

RESULTS: We identified 23 patients; 12 patients underwent esophagectomy and 11 patients underwent EMR as initial therapy. Patients were similar with respects to age (esophagectomy group: 65(9) vs EMR group: 65(12), p=0.91), gender (7 (64%) male vs 10 (83%), p=0.55), and comorbidity index (Charlson comorbidity index > 2; 2 (17%) vs 4 (36%), p=0.55). Most tumors arose from short segment (vs long segment) Barrett’s (9 (75%) vs 10 (91%), p=0.59) and one patient in each group had superficial invasion into the submucosa (T1sm1), the remainder having disease limited to the mucosa (T1m1-T1m3).

Esophagectomy was associated with 7 (58%) minor complications and 2 (17%) major complications (respiratory failure, anastomotic leak) whereas there were no complications related to EMR (p<0.01). Length of stay for esophagectomy was 18 (8) days. EMR successfully eradicated IMC in 10 patients (91%) with one eventually progressing to esophagectomy. On average, patients required 2 (1) endoscopies to achieve eradication. There was one recurrence associated with mortality in both groups on long-term follow-up (Kaplan-Meier estimate, p=0.532).

CONCLUSION: EMR was successfully eradicated IMC in 10/11 patients with similar long-term recurrence and mortality to esophagectomy patients. Patients with IMC may benefit from EMR as initial therapy by obviating the need for a complex and morbid operation.

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