ABSTRACT
Background: Esophagectomy has 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 a minimally invasive approach with lesser morbidity. This
study investigates the transition from esophagectomy to EMR for IMC with
respect to eradication rates, post-operative morbidity, and long-term
survival.
Methods: Patients diagnosed with IMC from 2005 to 2013 were
identified retrospectively. Beginning in 2009, preferred initial therapy
for IMC transitioned from esophagectomy to EMR. Esophagectomy was
performed either through a transthoracic or transhiatal technique. EMR
was repeated until resolution of IMC on pathology or progression of
disease. Continuous data are expressed as mean (SD) and analyzed using
Student’s t-test. Categorical data are presented as number (%)
and analyzed using Fisher’s exact 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, gender, and comorbidity index. Most
tumors arose from short segment (vs long segment) Barrett’s
(esophagectomy: 9 (75%) vs EMR: 10 (91%), p=0.59) and one patient in
each group had superficial invasion into the submucosa (T1sm1), the
remainder having mucosal disease. 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). EMR successfully eradicated IMC in 10
patients (91%) with one progressing to esophagectomy. Patients required
2 (1) endoscopies to achieve eradication. There was one mortality in
each group on long-term follow-up (log-rank test, p=0.62).
Conclusions: EMR was successful in eradicating 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.
Keywords: Endoscopic mucosal resection, esophagectomy,
intramucosal carcinoma, Barrett’s esophagus, early esophageal cancer.