RESULTS
A total of 26 consecutive patients were identified with a specimen
consistent with intramucosal carcinoma. Patient allocation is described
in Figure 1. One patient was excluded from the esophagectomy group as he
was identified on final pathology to have node positive disease. Two
patients were excluded from the EMR group when initial EMR showed
invasive deeper than T1sm1 and were referred for consideration of
oncologic resection. Therefore, 12 patients were analyzed in the
esophagectomy group and 11 patients were analyzed in the EMR group.
At baseline, patients in both groups were similar with respects to age
and gender. There was a trend towards patients receiving EMR having more
co-morbidities than patients undergoing esophagectomy. In the
esophagectomy group, the majority received an Ivor-Lewis (67%) versus a
transhiatal esophagectomy (33%). Most (75% vs 91%) intramucosal
adenocaricomas were found as part of a short (<3cm) segment of
Barrett’s in both groups and there were no differences in grade of
differentiation. Patient characteristics are presented in Table 1.
Of the 11 patients being treated by esophagectomy, one patient (1/12,
9%) experienced recurrence of disease 1.6 years after Ivor-Lewis
resection, culminating in mortality 5 years after initial surgery. In
the EMR group, one patients (9%) experienced progression of disease
after treatment 8 months after initial EMR for a T1m3 lesion and was not
a surgical candidate when nodal disease was discovered. One patient
(9%) was found to have recurrence of adenocarcinoma after initial
clearance by EMR on the 6th surveillance endoscopy, 4
years after his initial treatment. He was treated with a transhiatal
esophagectomy at that time. He had long segment of Barrett’s with
several biopsies showing high grade dysplasia. Successful eradication by
EMR was therefore accomplished in 10/11 (91%) patients with one
long-term recurrence treated with salvage esophagectomy in the EMR
group.
The morbidity of esophagectomy was significantly greater than with EMR.
Most patients undergoing esophagectomy (8/12 (75%)) had a
post-operative complication, two of which required re-intervention or
intensive care stays (17%). Median length of stay after esophagectomy
was 15 [10-22] days. Further postoperative outcomes by type of
operation are described in Table 2. EMR, on the other hand, was
performed as an outpatient procedure with low morbidity. In the EMR
group, no patient had 30-day complications related to the procedure. One
patient was admitted for 1 day after endoscopic control of bleeding
during EMR to ensure no rebleeding occurred. All other EMRs were
performed on an outpatient basis. A median of 1 [1-2] endoscopies
were required to achieve eradication. There was one major complication
in the EMR group: an anastomotic leak after transhiatal esophagectomy
performed upon recurrence of disease. Clinical outcomes are presented in
Table 2.
Estimated survival functions for 5 year mortality and disease-free
survival are presented in Figures 2 and 3. There was one mortality in
each group, leading to similar survival curves between esophagectomy and
EMR (p=0.62). Disease-free survival curves are parallel between both
groups, though one additional recurrence in the EMR group required
salvage esophagectomy for disease clearance. Average follow-up period
was 3.5 (1.6) years and 2.7 (1.1) years respectively (p=0.16).