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Development of Barrett's Esophagus After Esophagectomy: Experience at a Single Tertiary Center
Wei-Chung Chen*1, Lois L. Hemminger1, Steven P. Bowers2, Herbert C. Wolfsen1
1Gastroenterology, Mayo Clinic Florida, Jacksonville, FL; 2General Surgery, Mayo Clinic Florida, Jacksonville, FL
Background: Although patients who have undergone esophagectomy for esophageal cancer are at increased risk of reflux symptoms, there are few data available on the outcome of patients that subsequently develop intestinal metaplasia (IM) or neoplasia (dysplasia and carcinoma) after esophagectomy.
Aim: Evaluate baseline characteristics and outcome of patients who are diagnosed with Barrett’s esophagus (BE) after esophagectomy.
Methods: All patients undergoing diagnostic endoscopy for dysphagia or reflux symptoms and those undergoing surveillance endoscopy for BE with prior history of esophagectomy at a single center tertiary referral center between July 2004 and November 2015 were reviewed. Pertinent data related to pre-esophagectomy, esphagectomy, and post-esophagectomy were obtained for analysis.
Results: 13 patients (10 male; mean age 65.8; 55-79) were diagnosed BE after esophagectomy. The majority of the patients had average BMI of 26.1 (range 16.1 - 31.6). Eight patients (61.5%) had prior use of tobacco and alcohol. All patients had history of GERD. Six (46.1%) had family history of cancer. Majority of patients 12 (92.3%) underwent esophagectomy for esophageal adenocarcinoma with most cancer noted to have T2 stage. Five (38.5%) underwent minimally invasive esophagectomy (MIE) (Table 1). One patient underwent 2 separate esophagectomies for recurrent cancer. Average esophageal anastomosis was located in the upper esophagus at 24 cm from the incisor teeth. Three (23.0 %) were found to have positive margin for IM or dysplasia of the resected esophagus.
Average duration from esophagectomy to the subsequent diagnosis of IM or dysplasia during surveillance endoscopy was 44.7 months (range 6-162). 10 patients (77%) were found to have IM during the first EGD with positive biopsy. Four patients (31%) developed low grade dysplasia (LGD), high grade dysplasia (HGD), or EAC after esophagectomy. All patient underwent average of 11 endoscopies for surveillance (range 3-30), and majority 12 (92.3%) underwent minimum of annual surveillance for BE. Four patients (31%) developed anastomotic stricture and required repeated sessions of esophageal dilation. Eleven (84.6%) requiring twice daily PPI. Six patients (46.1%) underwent endoscopic treatment for BE, and RFA was most commonly used (Table 1). Three patients (23.0%) were found to have LGD/HGD or EAC on most recent esophageal biopsy (Figure 1).
Limitations: Retrospective study, single center study
Conclusion: Barrett’s esophagus was diagnosed in a subset of patients that have undergone complete esophagectomy for BE carcinoma, including patients with dysplasia and neoplasia that required endoscopic therapy. Larger prospective studies are required to better define which patients are at highest risk of recurrent disease and determine the role of surveillance endoscopy after esophagectomy.
Table 1. Patient Characteristics
| | | | Description
| | Age of diagnosis (y), mean ± SD | | | 65.8±7.5
| | Male sex, n(%) | | | 10(76.9)
| | Body mass index (kg/m2), mean ± SD | | | 26.1±4.8
| | History of GERD, n(%) | | | 13(100.0)
| | Smoking history, n(%) | | | 6(61.5)
| | Pre-esophagectomy/Esophagectomy Data | | | | | | Pre-surgery diagnosis of esophageal adenocarcinoma, n(%) | | 12(92.3)
| | | Type of esophagectomy | | | | | | MIE (2-Field or 3 Field) | 5(38.5)
| | | | Ivor-Lewis | 5(38.5)
| | | | Transhiatal esophagectomy | 2(15.4)
| | | | Other | 1(7.7)
| | | Final anastomosis (cm), mean ± SD | | 24.2±4.4
| | | Positive margin for IM/Dysplasia, n(%) | | 3(23.0)
| | Post-esophagectomy Data | | | | | | Duration from esophagectomy to formation of IM/Dysplasia (y), mean ± SD | | 3.6±3.3
| | | Long segment Barrett's esophagus, n(%) | | 4(30.8)
| | | Presence of dysplasia post-esophagectomy, n(%) | | 4(30.8)
| | | Use of proton pump inhibitor, n(%) | | 13(100.0)
| | | Total number of surveillance endoscopy, mean ± SD | | 11.4±7.0
| | | Annual surveillane of upper endoscopy, n(%) | | 12(92.3)
| | | Endoscopic treatment for Barrett's esophagus | | | | | | EMR, n(%) | 2(15.4)
| | | | RFA, n(%) | 6(46.2)
| | | | PDT, n(%) | 2(15.4)
| | | | Cryotherapy, n(%) | 2(15.4)
| | | Use of more than one type of endoscopic treatment for Barrett's, n(%) | | 2(15.4)
| | | Most recent pathology from esophageal biopsy normal squamous/IM, n(%) | | 10(77.0)
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MIE = Minimally invasive esophagectomy, IM = Intestinal metaplasia, EMR = endoscopic mucosal resection, RFA = radiofrequency ablation, PDT = Photodynamic therapy 
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