Treatments
Prior to 2009, patients found to have intramucosal carcinoma on
surveillance endoscopy for Barrett’s esophagus were referred for
esophageal resection. Esophagectomy was performed by one of two surgeons
(H.H. or D.B.) either by either Ivor-Lewis or transhiatal technique.
Operative and post-operative care was at the discretion of the treating
surgeon. Postoperatively, patients were not kept intubated and were not
routinely transferred to the intensive care unit, but are rather kept in
a specialized step-down area. Nasogastric tubes were removed on
post-operative day 2 and diet advanced thereafter. Chest tubes were
removed on postoperative day 3-4 for patients undergoing a transthoracic
approach. Patients were then followed with a control visit 6 weeks after
surgery and upper endoscopy at 3 months, 6 months, and then yearly if
asymptomatic.
After July 2009, endoscopic mucosal resection was introduced at our
institution. All patients with a diagnosis of intramucosal carcinoma on
biopsy were evaluated for endoscopic mucosal resection as a preferred
approach. EMR was performed using the Duette Multi-Band Mucosectomy
device (Cook Medical, Bloomington, IN) (17). Nodular lesions were
identified using a combination of location of prior biopsy sites,
mucosal and vascular pattern abnormalities, and narrow band imaging. We
used a cap-fitted endoscope to aspirate and band the selected mucosal
area followed by a snare resection supplemented with electrocautery
according to the manufacturer’s instructions. We used this technique to
resect nodular lesions either as a single specimen or in a piecemeal
fashion to achieve complete gross resection. Patients were subsequently
followed every 3 months with repeat endoscopies and repeat EMR treatment
if persistence of nodularity or dysplasia. Once visually and
pathologically clear, patients were followed at 3 months, 6 months, then
surveyed yearly with four-quadrant and random biopsies.