Limited resection for early adenocarcinoma in Barrett's esophagus

Abstract

Objective: To assess the extent of disease in patients with pT1 esophageal adenocarcinoma and to evaluate the feasibility and outcomes of a limited surgical approach.

Summary background data: Radical esophagectomy with systematic lymphadenectomy is widely advocated as the treatment of choice in patients with early adenocarcinoma of the distal esophagus. This approach, however, is associated with substantial complications and long-term side effects. The extent of resection necessary to achieve cure in such patients is not clear.

Methods: Seventy-one patients with pT1 adenocarcinoma of the distal esophagus underwent transmediastinal or transthoracic esophagectomy with two-field lymphadenectomy. Twenty-four patients with uT1N0 tumors underwent a limited resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic pedicled jejunal segment. The two groups were compared for extent and multicentricity of the primary tumor and associated high-grade dysplasia, pattern of lymph node metastases, complications, deaths, and outcome of surgical treatment.

Results: Multicentric tumor growth or associated high-grade dysplasia was observed in 60.6% of the resection specimens. Complete resection of the tumor and the entire segment with intestinal metaplasia was achieved in all patients, irrespective of the surgical approach. Patients undergoing limited resection had fewer complications. Lymph node metastases or micrometastases were present in none of the 38 patients with tumors limited to the mucosa (pT1a) versus 10 of the 56 (17.9%) patients with tumors invading the submucosa (pT1b). Distant lymph node metastases occurred only in patients with more than three positive regional lymph nodes. Lymph node metastases were prognostic, but the pT1a/pT1b category and the surgical approach were not. The mean Gastrointestinal Quality of Life Index after limited resection did not differ from that of healthy controls: 20 of the 24 patients were completely asymptomatic.

Conclusions: In patients with early adenocarcinoma in the distal esophagus, resection of the distal esophagus and esophagogastric junction, with regional lymphadenectomy and jejunal interposition, is an attractive limited surgical alternative to radical esophagectomy.

Figure 1. (A) Limited resection of the distal esophagus, esophagogastric junction, and proximal stomach. (B) Reconstruction by interposition of a pedicled isoperistaltic jejunal segment.

Figure 2. Prevalence of early tumors (pT1A and pT1b category) among all resected adenocarcinomas of the distal esophagus at the authors’ institution, 1982–1988 (n = 106), 1989–1994 (n = 113), and 1995–1999 (n = 149).

Figure 3. Cumulative survival of patients with pT1 adenocarcinoma in the distal esophagus who underwent a transmediastinal or transthoracic esophagectomy (n = 71) or limited resection (n = 24) for tumors staged as uT1. Postoperative deaths are included. There was no significant difference.

Figure 4. Cumulative survival of patients with pT1a (n = 38) and pT1b (n = 56) adenocarcinoma in the distal esophagus. There was no significant difference.

Figure 5. Cumulative survival of patients with pT1 adenocarcinoma in the distal esophagus with (pN+, n = 10) and without (pN0, n = 84) lymph node metastases (P < .05).