Esophagectomy has been the standard of care for patients with esophageal adenocarcinoma (EAC). This approach, however, has:
The surgery itself involves alteration of normal anatomy—the loss of the gastroesophageal sphincter. The stomach may no longer empty well, and there is risk of developing gastroesophageal reflux or Barrett esophagus after surgery. Complications such as anastomotic leak in the chest as well as cardiac and pulmonary problems also are possible. In addition, it typically takes weeks for the multiple incisions to heal fully and for patients to begin eating well.
Mayo Clinic is among a handful of medical centers that now offer minimally invasive endoscopic mucosal resection (EMR), alone or in combination with other mucosal ablation techniques such as photodynamic therapy (PDT), to patients with mucosal (T1a) EAC.
During EMR, a liquid is injected under the lesion and then an endoscope is used to shave off the lesions. EMR is typically performed on an outpatient basis. Once the tumor invades the second layer of tissue or when patients present with symptoms such as dysphagia, traditional surgery is typically recommended. For this reason, regular endoscopic surveillance is critical for patients with Barrett's esophagus who have been treated endoscopically.
The major benefits associated with EMR are elimination of hospital stay and reduced mortality and morbidity. Patients typically recover more quickly from EMR than those treated surgically and can resume eating full meals a few days after the procedure.
Possible complications from EMR include esophageal perforation and a slightly increased risk of bleeding (about 5% of patients treated at Mayo). Delayed possible complications include esophageal stricture (scarring), which typically occurs a few weeks after the procedure and sometimes after multiple procedures.
Follow-up endoscopic surveillance, with biopsies and EMR as indicated, should be performed every 3 months during the first year of follow-up, every 6 months during the second year, and yearly thereafter.
Because the endoscopic approach is new and performed only at select referral centers, outcome data are just emerging.
In a retrospective study of 178 Mayo Clinic patients who received a diagnosis of mucosal EAC between 1998 and 2007, 132 (74%) were treated with EMR and 46 (26%) were treated surgically. Endoscopic therapy consisted of EMR alone or in combination with PDT.
Mayo researchers found that overall survival and cumulative mortality in the 2 treatment approaches were comparable at 5 years. Further analysis of the study data suggests that treatment modality was not a significant predictor of survival. In addition, recurrent carcinoma was detected in 12% of the patients treated endoscopically, all of whom were successfully re-treated endoscopically with no impact on overall survival.
In summary, endoscopic therapy with EMR in conjunction with ablative therapy appears to be a reasonable alternative to esophagectomy in patients with mucosal EAC. Overall survival appears to be comparable with low recurrence rates.
The Mayo Clinic Barrett's esophagus unit offers a multidisciplinary approach to: