The increasing adoption of endoscopic, ablative and expectant treatment options for patients with high grade dysplasia (HGD) in Barrett's esophagus has created considerable confusion regarding the ideal treatment choice. This is due to a limited understanding of the outcomes associated with surgical resection for HGD and extrapolation of data derived from patients undergoing an esophagectomy for invasive cancer. The purpose of our study was to document the perioperative and symptomatic outcomes, as well as long-term survival, following esophagectomy for HGD of the esophagus.
Methods: The study population consisted of 38 patients who underwent esophagectomy for biopsy proven HGD between 10/1999 and 6/2005. Three patients were excluded from evaluation due to obvious tumor on upper endoscopy. Patients were evaluated regarding 10 different foregut symptoms and administered a 10-question appraisal of eating and bowel habits. Outcome measures included morbidity and mortality, the prevalence of invasive cancer, assessment of symptomatic and functional alimentary outcome, patient satisfaction, and long-term survival. Median follow-up was 32 months (range 7-83).
Results: Thirty-day perioperative and in-hospital mortality was zero. Complications occurred in 37% (13/35) and median length of stay was 10 days. Occult adenocarcinoma was found in 29% (10/35) of surgical specimens (intramucosal in 4;submucosal in 5;node positive in 1). Patients consumed a median of 3 meals per day, most (76%, 26/34) had no dietary restrictions, and two-thirds (23/34) considered their eating pattern to be normal or only mildly impacted. Meal size, however, was reported to be smaller in the majority (79%, 27/34) of patients. Median body mass index (BMI) decreased slightly after surgery (28.6 v. 26.6, p>0.05) but no patients’ BMI went below normal. The number of bowel movements/day was unchanged or less in a majority (82%) of patients although 15 of 34 (44%) reported loose bowel movements, which occurred less often than 1/wk in 10 of the 15. One patient had symptoms of dumping. Mean symptom severity scores improved for all symptoms except dysphagia and choking. Four patients developed foregut symptoms that occurred daily. Most patients (82%) required at least one post-operative dilation for dysphagia. Almost all (97%) patients were satisfied. Disease-free survival was 100% and overall survival was 97 % (34/35) at a median of 2.7 years.
Conclusion: Esophagectomy is an effective and curative treatment for HGD. It can be performed with no mortality, expectable morbidity and good alimentary outcome. These data provide a gold standard for comparison to alternative therapies.