Endoscopic versus surgical therapy for Barrett’s esophagus neoplasia

Abstract

Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal cancer. Though surgery can completely resect the cancer and the affected lymph nodes, it carries significant morbidity and mortality (often exceeds 2%). New developments in endoscopy have provided less-invasive therapies that can also be used to stage tissue invasion of cancer; they include esophageal mucosal resection (EMR) and endoscopic submucosal dissection. Additional endoscopic therapies include photodynamic therapy, radiofrequency ablation (RFA) and argon plasma coagulation. Combining EMR that targets the cancer and RFA that targets the surrounding Barrett’s esophagus offers an alternative to the operative approach when there is no lymph node metastasis. Arguments for surgical esophagectomy include concern for missed lymph node metastasis and incomplete endoscopic resection. Based on EMR’s high neoplasia eradication rate and its fewer and more manageable complications, EMR, especially when combined with RFA, appears to be a viable alternative to surgery in early submucosal cancers, that is, sm1.

Keywords:

• Barrett’s esophagus
• conventional endoscopy
• endoscopic mucosal resection
• endoscopy
• esophageal disease
• esophagectomy
• radiofrequency ablation

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Esophagectomy has been the conventional treatment for early Barrett’s neoplasia, but is associated with increased operative mortality and morbidity.

• By selecting endoscopic therapy over surgery one fears missing lymph node metastases.

• In submucosal cancer, lymph node metastases ranges from 14 to 45%; but in subtle submucosal infiltration (sm1 or <500 μm), the rate of lymph node metastasis is 0–14%.

• Compared to esophagectomy, endoscopic ablative therapy including photodynamic therapy, radiofrequency ablation, argon plasma coagulation, esophageal mucosal resection (EMR) and endoscopic submucosal dissection is associated with decreased procedure-related complications.

• EMR (removes targeted superficial tissue) and endoscopic submucosal dissection (removes large en bloc strips of mucosa) are able to stage and treat early esophageal neoplasms.

• EMR for focal visible lesions, combined with radiofrequency ablation or photodynamic therapy for the remaining Barrett’s esophagus mucosa have yielded impressive results in terms of complete ablation of early cancer.

• EMR’s adverse events include stricture formation, bleeding and, rarely, perforation.

• Concern for endoscopic ablative therapies, especially photodynamic therapy, is that partially ablated Barrett’s epithelium might heal with buried metaplastic tissue.

• Endotherapy is associated with higher neoplasia recurrence rate, but can be retreated by endoscopic methods.

Notes