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.