SAN FRANCISCO — Patients with esophageal adenocarcinoma may benefit from reduced postsurgical morbidity after undergoing vagal-sparing esophagectomy, Dr. Daniel S. Oh reported at the annual clinical congress of the American College of Surgeons.
Compared with other surgical options, “vagal-sparing esophagectomy is associated with reduced morbidity and shorter length of stay, with similar early outcomes,” said Dr. Oh, speaking on behalf of a team of surgeons at the University of Southern California led by Dr. Thomas R. DeMeester.
Pioneered at USC, the vagal-sparing procedure preserves the vagal nerves and gastric reservoir. The diseased esophagus is removed from the mediastinum with a vein-stripping tool and is replaced by a section of the patient's colon or a gastric tool formed from the greater curvature of the stomach. The procedure is aimed at reducing postsurgical gastrointestinal side effects of traditional esophagectomy, such as dumping syndrome, diarrhea, and reduced stomach capacity.
The incidence of esophageal adenocarcinoma is rising faster than for any other cancer, noted Dr. Oh, who presented an 18-year retrospective study of the USC experience with surgical options for treating this increasingly important malignancy.
He reviewed 78 cases of esophageal adenocarcinoma with invasion through the basement membrane into the lamina propria, but not through the muscularis mucosa. Median follow-up was 38 months.
The cases included 65 related to Barrett's esophagus and 13 cases associated with intestinal metaplasia of the cardia (CIM). Gastroesophageal reflux disease symptoms were present in 63 of 65 of the Barrett's cases, and 10 of 13 of those associated with CIM. The symptoms were present for 20 years, on average, in Barrett's patients vs. 8 years for CIM patients. Infection with Helicobacter pylori was rare in both groups; just three of the Barrett's patients, and none of the CIM patients had infection.
A subgroup of patients underwent lymphadenectomy; just 1 lymph node in 1,020 sampled (1 patient in 23) showed evidence of metastasis with hematoxylin and eosin staining. Immunohistochemistry showed evidence of micrometastasis in 3 of the 848 lymph nodes examined (2 of 19 patients).
“Based on the low prevalence of metastasis in our patients, we began looking at the extent of resection [being performed], in order to lessen the morbidity of esophagectomy,” Dr. Oh said.
Only 2 complications were seen in the 20 patients treated with vagal-sparing esophagectomy, compared with 11 complications in the 23 patients treated with en bloc esophagectomy and 13 complications in the 31 patients who had a transhiatal esophagectomy (THE), a procedure developed at the University of Michigan, Ann Arbor. Four patients underwent simple transthoracic esophagectomy due to complicating factors such as prior radiation that precluded a typical transhiatal esophagectomy with an anastomosis in the neck. No patient in any group had residual signs of Barrett's esophagus.
The hospital stay was also shorter: 12 days after vagal-sparing esophagectomy, compared with 22 days after en bloc resection and 17 days after THE.
The overall operative mortality was nearly 3% (2 patients). Two patients died of systemic disease, one at 2 years and one at 7 years following resection.
“There was no difference in survival based on the type of surgical resection performed,” said Dr. Oh, but he noted that the 5-year follow-up was longer for the en bloc resection patients than for the others.
In upper endoscopies performed by the surgeon prior to surgery, 53 of 78 patients had a visible lesion, and the lesion was cancerous in 48. In five patients, high-grade dysplasia was diagnosed within a visible lesion. Among 25 patients with no visible lesion, 16 had cancer and 9 had high-grade dysplasia.
The tumor origin in almost half of the patients in the series was within 1 cm of the gastroesophageal junction. There was a “progressive decrease in the frequency [of tumors] further up the esophagus,” Dr. Oh said.
An esophageal adenocarcinoma lesion is visible on endoscopy. Courtesy Dr. Daniel S. Oh