Elective Esophagectomy of Early Barrett's Adenocarcinoma After Endoscopic Mucosal Resection (EMR) Due to Incompleteness Or T1 sm Stages

Abstract

EMR has a diagnostic value in staging early Barrett's neoplasia (BE-Npl), especially with regard to the discrimination between mucosal and submucosal (sm) infiltration. Furthermore, it has the potential of curative resection in early Barrett's adenocarcinoma. Prerequisites for cure are complete local tumor resection and histopathological confirmation of mucosal neoplasia in the EMR specimen. In case of sm-infiltration surgical resection is mandatory due to an increased risk of lymph node metastases. Methods: A prospectively collected database of EMR (cap-technique) in either diagnostic or therapeutic intention of consecutive patients with early BE-Npl was analyzed with regard to surgical interventions. Indications for surgery were incomplete resection with the inability of proceeding further endoscopic resection, usually due to scar formation (technical failure) and/or histopathological proof of sm- infiltration in the EMR specimen. Results: Of 89 patients with early BE-Npl treated between 11/1999 and 12/2005 14 (16%) underwent surgical resection in 3 different hospitals with transhiatal (n = 4), transthoracic (n = 8; 7/8) or abdominocervical esophagectomy (n = 2) (mean age 66 (45-82) years; LSBE n = 10, SSBE n = 4). Indications for surgery were histopathological proof of sm-infiltration in 9, incomplete EMR in 5 patients (due to stenosis n = 3 or widespread residual neoplasia n = 2). Histopathology of the surgically resected specimen showed no residual neoplasia in 7 of 9 patients (78%) with sm-involvement, residual neoplasia of the same stage (m-type) in 4 and downgraded residual neoplasia in 2 patients. None of these 13/14 patients had lymph node metastases. The final diagnosis in one patient was pT2, N1 who had been referred for diagnostic EMR. Complications: One patient died after surgery due to a severe haemorrhage with shock and unsuccessful resuscitation (1/14 = 7%). Other complications were anastomotic stricture (n = 1), anastomotic insufficiency (n = 2), cardiac arrhythmias (n = 2), transient cerebral confusion with drop (n = 1) and pneumonia (n = 2). Conclusion: These data confirm the diagnostic value of EMR with regard to adequate patient stratification according to the histopathological stage of disease. Patients with sm-infiltration should be referred for surgery including lymphadenectomy considering the potential risk of lymph node metastases even though the lesion was completely removed in 78% by EMR in this subgroup. With regard to high surgical morbidity and mortality rates it seems necessary to improve endoscopic resection techniques in patients requiring multiple resections to avoid stricture formation and consecutive inability of proceeding EMR.