Laparoscopic transgastric esophageal mucosal resection for high-grade dysplasia

BACKGROUND: High-grade dysplasia of the esophageal mucosa has been shown to be a precursor to adenocarcinoma. In addition to esophagectomy, multiple ablative endoscopic techniques have evolved for the management of this condition. As a surgical alternative to esophagectomy, we describe for the first time a new option in the treatment of high-grade dysplasia. MATERIALS AND METHODS: Two patients with a history of gastroesophageal reflux disease (GERD) underwent upper gastrointestinal endoscopy which demonstrated high-grade dysplasia of the distal esophagus. The first patient had a short segment (0.5-1.0 cm), and the second patient had a longer (2 cm) segment of dysplasia. The patient is placed in the modified lithotomy position. Five trocars are placed as if to perform a fundoplication. A complete circumferential mobilization of the esophagus is performed. The short gastric vessels are divided with the harmonic scalpel, to free up the fundus of the stomach. An anterior horizontal gastrotomy is performed three to four centimeters below the gastroesophageal junction. A solution of epinephrine and normal saline (1:100,000) is injected into the mucosa at the Z-line and, utilizing specially designed hook electrocautery, the mucosa is incised circumferentially around a lighted bougie. Using blunt dissection the mucosa is undermined, elevated, and excised in four quadrants. Three centimeters of the distal esophageal mucosa are resected. The gastrotomy is then closed using a linear stapler, and a 360 degrees fundoplication is performed around a 50 Fr bougie. RESULTS: High-grade dysplasia was identified in the specimens from both patients; however, neither patient was found to have carcinoma in situ or invasive esophageal cancer. Our first patient has been followed for twenty months, the second for ten months. Both patients underwent routine upper gastrointestinal endoscopy for surveillance of the healing process. At eight months, the mucosa of the first patient showed complete regeneration of squamous epithelium. Our most recent patient appears to be progressing without complications and has also demonstrated normal squamous epithelium at ten months postoperatively, without changes of Barrett's epithelium. CONCLUSION: The technique of laparoscopic transgastric esophageal mucosal resection is feasible and may be proven to be an alternative to esophagectomy for the management of high-grade dysplasia.     

Recent advances in endoscopic resection for esophageal cancer

The indications for endoscopic resection (ER) in esophageal cancer are limited to cases without lymph node metastasis because it is a local therapy. The relationship between cancer depth and lymph node metastasis has been clarified according to the pathologic analysis of lymph nodes removed during esophagectomy for early esophageal cancer. Cancer invasion remaining in the lamina propria mucosa rarely metastasizes to the lymph nodes, and ER is thus indicated. ER allows the esophagus to be preserved and is less invasive, enabling the specimen to be examined pathologically. Lesions extending to a large area can be resected by repeated endoscopic mucosal resection (EMR), but have recently been resected en bloc in the endoscopic submucosal dissection (ESD) procedure, which is also indicated for the treatment of gastric cancer. The selection of EMR or ESD depends on the size of the lesion, the technique of the surgeon, the time the patient can safely spend under anesthesia, and economic management. ER is now employed in T1a-MM, SM1 cases without lymph node metastasis, although some require additional treatment including surgery after pathologic examination of the resected lesions.     

Outcomes and health-related quality of life after esophagectomy for high-grade dysplasia and intramucosal cancer

HYPOTHESIS: The reported morbidity and mortality associated with esophagectomy for high-grade dysplasia (HGD) and intramucosal cancer (IMC) have led asymptomatic patients to consider less invasive and possibly less effective treatments. This study provides a critical assessment of outcomes and health-related quality of life (HRQL) after esophagectomy for HGD and IMC. DESIGN: Cohort analytic study. SETTING: Section of thoracic surgery at a tertiary referral center. PATIENTS: All patients who presented between May 1991 and February 2003 with a biopsy-proven diagnosis of Barrett esophagus with HGD or IMC were assessed. MAIN OUTCOME MEASURES: Prospective analysis of postoperative morbidity, mortality, HRQL, and gastrointestinal symptoms. RESULTS: Follow-up was complete in 36 patients. Mean follow-up was 4.9 years (range, 0.5-12.0 years). The incidence of postoperative invasive cancer was 39%, with stages ranging from I to IIB. There were 4 major complications (11%) and no operative mortality. Twenty-eight patients were alive, with a cancer-free survival of 85%. The HRQL outcomes (Medical Outcomes Study 36-Item Short-Form Health Survey) were comparable with those of age- and sex-matched controls. Significant differences in postesophagectomy gastrointestinal symptoms were seen with a decreased incidence of heartburn (P < or = .001) and increased requirement for a slower speed of eating. Twenty-two (79%) of the 28 patients described their current eating pattern as "normal or insignificantly impacted." CONCLUSIONS: Esophagectomy for HGD and IMC can be accomplished with low morbidity and mortality. Furthermore, most patients are able to resume a normal eating pattern, and postoperative HRQL can be equivalent to that of the general population.     

Complications of Barrett's esophagus: indications for esophageal resection with special reference to high-grade dysplasia

BACKGROUND: Columnar lined oesophagus (Barrett's oesophagus) can sometimes be associated with complications such as stricture, ulcer and dysplasia. In some selected cases there is an indication for oesophageal resection. METHODS: From 1983 to 1997, 12 patients underwent oesophagectomy for "complicated" Barrett's oesophagus. All patients had gastroesophageal reflux and Barrett metaplasia for many years. Ten of them were symptomatic, and pH-manometric alterations as well as alterations were noted at biliary scintigraphy. Ten patients had intestinal metaplasia. Two patients had previous antireflux operations. Four had a long (3-5 cm) and undilatable stricture. One was affected by a perforating ulcer. One patient had an indefinite grade dysplasia but endosonography revealed high suspicion of cancer. Six patients had a high-grade dysplasia. Operative technique consisted of a transhiatal oesophagectomy in nine cases and a laparotomic and right thoracotomic oesophagectomy (Ivor-Lewis) in two. RESULTS: There was no 30-day mortality; three post operative complications were observed. One of the four patients suffering from stricture died four years after intervention due to non-related causes; the other three are still living and regularly feed per os after 12, 9 and 7 years. The patient with ulcer is still living after 6 years and regularly feeding per os. The patient suffering from an indefinite grade dysplasia had an adenocarcinoma (stage IIa) on the operative specimen. The patient is still living after 2 years. Three patients operated for high-grade dysplasia had an adenocarcinoma on the specimen. Two patients (stage I) are living after 3 and 5 years. One patient (stage IIa) died after 19 months with recurrence. CONCLUSIONS: In case of non neoplastic "complicated" Barrett's oesophagus the indication for the oesophageal resection can be considered as the extreme useful therapy only after an accurate selection of patients. Especially in case of high-grade dysplasia, the great incidence of unexpected adenocarcinoma indicates oesophagectomy for patients who are suitable for surgery.     

Oesophageal resection for high-grade dysplasia in Barrett's oesophagus

BACKGROUND: The aims of this study were to evaluate the prevalence of invasive cancer in patients with high-grade dysplasia in Barrett's oesophagus and to verify whether a second endoscopy with multiple biopsies could improve the accuracy of preoperative diagnosis. In addition, the mortality, morbidity and survival rates in patients with high-grade dysplasia having oesophageal resection were recorded. METHODS: Fifteen patients were observed from 1982 to 1998; the first seven patients were offered primary oesophageal resection after diagnosis. The other eight patients underwent a second endoscopy with a median of 12 biopsies examined. All later underwent oesophageal resection. RESULTS: Invasive adenocarcinoma was found in five patients, with a minimal difference between the first and second periods (two of seven versus three of eight). There were no perioperative deaths. Early morbidity was observed in eight patients and late morbidity in four. The actuarial survival rate was 79 per cent at 5 years. The Karnofsky status was unchanged from preoperative values in 13 of 15 patients after a median follow-up of 46 months. CONCLUSION: These patients with high-grade dysplasia had a 33 per cent probability of harbouring invasive oesophageal carcinoma but even a second endoscopy failed to identify patients with invasive tumour. Oesophagectomy was performed with no deaths and remains a rational treatment in patients fit for surgery.     

内镜黏膜下隧道法切除早期食管癌及癌前病变的应用分析

目的 探讨内镜黏膜下隧道法在切除早期食管癌及癌前病变中的应用价值.方法 17例术前超声内镜检查判断病变局限于黏膜层,经黏膜活检发现食管上皮局灶癌变或重度不典型增生的患者,采用黏膜下隧道法的内镜下早期癌切除.结果 17例中,术后病理确诊鳞状上皮增生伴黏膜慢性炎4例,重度不典型增生5例,高至中分化鳞癌8例,其中T1a期7例,T1b期1例.有2例切除黏膜边缘重度不典型增生,1例黏膜下层切缘见癌细胞,其余病例均病灶完整切除.术后1例患者因迟发性出血转开胸手术治疗,其余患者均恢复良好.结论 黏膜下隧道法切除黏膜内早期食管癌及癌前病变安全、有效,更符合直视、充分暴露的外科原则,明显减少出血、穿孔的并发症风险,但其对病灶切除范围判断有一定困难,需在手术中充分注意.     

Esophageal preservation in esophageal high-grade dysplasia and intramucosal adenocarcinoma

The management of esophageal high-grade dysplasia (HGD) and intramucosal adenocarcinoma remains controversial. Because lymph node involvement is unlikely in this setting, interest in the treatment strategies for esophageal preservation has grown. Esophageal preservation indicates any endoluminal procedure that is used in an attempt to completely eradicate disease while preserving the anatomic structure of the esophagus. The goal of esophagus-preserving approaches is to provide definitive therapy while avoiding the morbidity of esophagectomy. This article describes the patient selection and the status of currently available esophagus-preserving options, and discusses the strategy for treating HGD and intramusocal adenocarcinoma.     

Barrett's: evolving techniques for dysplasia detection and endoscopic resection

Advanced endoscopic imaging techniques have made the early diagnosis of neoplastic lesions in Barrett's esophagus easier. A new chapter in minimal invasive cancer therapy has been opened. Endoscopic treatment of early neoplasia in Barrett's esophagus (high-grade intraepithelial neoplasia and mucosal adenocarcinoma) has become the method of choice in most countries. Long-term results for endoscopic treatment in a large group of patients are now available. These emerging data suggest that endoscopic therapy is safe and highly effective with long-term complete remission rates of more than 94%. All visible lesions should be treated by endoscopic resection for histologic confirmation of the neoplastic lesion rather than by ablative techniques. After successful endoscopic resection of all visible and localizable high-grade intraepithelial neoplasia and mucosal cancer, ablative treatment of the remaining Barrett's epithelium at risk should be performed to reduce the rate of recurrent or metachronous neoplasia.     

Pneumothorax during esophageal endoscopic mucosal resection

We report a case of pneumothorax occurring during esophageal endoscopic mucosal resection (EEMR). A 53-year-old man with early esophageal carcinoma was scheduled for EEMR under general anesthesia with artificial ventilation. During the operation, arterial oxygen saturation measured by pulse oximeter suddenly decreased from 99% to 84%, and airway pressure increased from 15 cmH2O to 25 cmH2O. Right pneumothorax was detected and chest drainage was performed. On resumption of the operation, perforation of the esophagus was identified and repaired. The esophageal perforation and pleural injury were thought to have been caused by endoscopic operation. Although a rare complication in EEMR, pneumothorax should be considered when sudden' hypoxia occurs during EEMR.     

Invasive carcinoma after endoscopic ablative therapy for high-grade dysplasia in Barrett's oesophagus

BACKGROUND: Patients with high-grade dysplasia (HGD) in Barrett's oesophagus carry a significant risk of developing adenocarcinoma. Endoscopic mucosal resection (EMR) and photodynamic therapy (PDT) aim at the radical ablation of the dysplastic area. METHODS: We used EMR to resect the macroscopic area of dysplastic mucosa followed by PDT to eliminate residual disease. PDT was performed after oral administration of 5-aminolevulinic acid (ALA, 40 mg/kg), using fractionated illumination 3 and 6 h later with 630 nm light at 100 J/cm(2) through an endoscopic balloon diffuser. RESULTS: We report 2 patients who developed adenocarcinoma shortly after incomplete endoscopic ablation of Barrett's epithelium. In a 61-year-old man with HGD in 8-cm Barrett's segment, HGD persisted 3 months after treatment. The oesophagectomy specimen showed a 2.3-cm pT2N0M0 adenocarcinoma in Barrett's. In a 69-year-old woman with extensive HGD in 5-cm Barrett's, HGD persisted after 3 PDT sessions in 1 year. Adenocarcinoma occurred 6 months after treatment. The oesophagectomy showed a pT1bN0M0 adenocarcinoma and extensive multifocal HGD in Barrett's. CONCLUSIONS: The combination of EMR and PDT may be a promising option for local treatment of patients with HGD in Barrett's oesophagus, provided all dysplastic tissue can be removed. Currently it should be offered only to patients who are willing to participate in a clinical trial with an intensive endoscopic follow-up programme.     

Evaluation of endoscopic mucosal resection for superficial esophageal carcinoma

Esophageal superficial carcinoma safely can be resected surgically or endoscopically. We evaluated indications for endoscopic mucosal resection (EMR) and optimal treatment modality for superficial carcinoma of the esophagus based on clinical and pathologic analyses. Between January 1, 1984, and September 30, 1999, 113 patients with superficial cancer of the esophagus underwent surgical or endoscopic resection (n = 33 patients, 36 lesions). The two-channel method, esophageal EMR-tube method or EMR cap-fitted panendoscope was used. Mucosal and submucosal cancers were classified to be epithelial layer (m1), proper mucosal layer (m2), muscularis mucosae (m3), upper third of the submucosal level (sm1), middle third of the submucosal layer (sm2), or the lower third of the submucosal level (sm3) cancers, according to criteria of the Japanese Society for Esophageal Disease. Absolute indication for EMR was restricted to m1 or m2 cancers, and relative indications for EMR included m3 or sm1 lesions. In our department, indications for EMR were not related to size or circumference of lesions. Lymph vessel invasion and lymph node metastasis markedly increased in lesions that infiltrated the lamina muscularis mucosa (m3). All lesions resected with use of EMR were 0-II (flat), and the depth of invasion in 10 0-IIa or 0-IIb lesions was m1 or m2. Twenty-one 0-IIc lesions were distributed widely from m1 to sm1. All 0-IIa+IIc lesions were m3 or sm1. Preoperative diagnosis accurately was established preoperatively in 61% of patients. Complications related to EMR were detected in 21% of patients and included perforation, stenosis, and hemorrhage. Ten patients also received radiotherapy, chemotherapy, or esophagectomy with lymph node dissection after use of EMR. No such combination therapy was administered in six patients with m3 lesions, but without lymph vessel invasion. All patients treated with use of EMR, including patients with m3 cancer who did not receive additional treatment, are living without recurrence. Local resection with use of EMR could be regarded to be the preferred treatment of superficial esophageal cancers limited to the lamina propria mucosae. Endoscopic mucosal resection also could be regarded to be the preferred treatment of m3 cancer without lymph vessel invasion. Use of additional therapy, such as radiotherapy, allows the use of EMR for m3 cancer with lymph vessel invasion or sm1 cancers.     

Endoscopic mucosal resection and vagal-sparing esophagectomy for high-grade dysplasia and adenocarcinoma of the esophagus

Once a rare tumor, adenocarcinoma of the esophagus is currently the cancer with the fastest rising incidence in America. In addition to the increasing prevalence of the disease, surveillance programs for patients with Barrett's have led to the identification of increasing numbers of patients with high-grade dysplasia or early-stage esophageal adenocarcinomas. Although traditional esophagectomy is curative in the majority of these patients, associated morbidity and mortality remains a hurdle for patient acceptance of the procedure. New endoscopic and surgical therapies offer the potential of decreased morbidity, but do not include a lymphadenectomy, and consequently, are not appropriate in patients that have a significant risk of lymph node metastases. Endoscopic mucosal resection allows precise determination of the depth of tumor invasion and facilitates accurate local staging of early esophageal cancers. A vagal-sparing esophagectomy accomplishes the goal of removing the diseased esophagus while minimizing the physiologic impact of an esophagectomy in patients with early-stage esophageal cancer.     

内镜下黏膜切除术治疗早期食管癌及癌前病变

目的 探讨内镜下黏膜切除术(EMR)治疗早期食管癌及癌前病变的临床价值.方法 分析2006年1月至2012年2月福建省立医院消化内镜中心90例行食管EMR治疗早期食管癌及癌前病变的临床资料,评价EMR手术的安全性及疗效.结果 90例中食管上段(距门齿15～23 cm)病变16例,食管中段病变(距门齿23 ～ 32 cm)52例,食管下段病变(距门齿32～ 40 cm)22例;病灶平均直径为(2.05±3.12) cm.所有病变均顺利完成EMR.切除标本大小为(3.55±2.71)cm.手术时间为(18 ～ 125) min,出血量为(10 ～70) ml,病灶整块切除率为24.4％(22/90).术中出血4例(4.4％),术后迟发性出血2例(2.2％),无1例食管穿孔发生;术后食管狭窄3例(3.3％),均予保守治疗好转.90例均接受随访,随访时间(4 ～60)个月,术后5年内病变复发5例,总复发率为5.6％ (5/90),无癌复发死亡病例.结论 EMR治疗早期食管癌及癌前病变具有安全性和有效性.     

腔镜在食管癌根治术中的应用(附40例报道)

目的探讨电视胸腔镜、腹腔镜及纵隔镜联合微创根治食管癌的可行性。方法2004年4月至2006年5月,联合使用腔镜行食管癌根治40例,其中开胸联合腹腔镜10例,小切口辅助胸腔镜联合腹腔镜20例,纵隔镜联合腹腔镜4例,纵隔镜联合开腹6例。结果34例腹腔镜游离胃均获成功,无出血,清除腹腔淋巴结(5·5±1·9)枚。小切口辅助胸腔镜下食管癌根治20例,无中转开胸,清扫纵隔淋巴结(10·3±2·7)枚,术后心律失常4例,胸腔出血1例,功能性胃梗阻1例;纵隔镜食管癌切除10例,术中出血1例,术后声音嘶哑3例。40例随访1~20个月,无肿瘤复发转移,无死亡。结论腔镜联合切除食管癌安全可行,小切口辅助胸腔镜下食管癌切除兼顾开放手术和纯胸腔镜手术的优点,是值得推广的手术方式。