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Long-Term Follow-Up of Reflux Associated Mucosal Damage in the Remnant Esophagus Following Transthoracic Esophagectomy for Esophageal Cancer
Hans F. Fuchs*1, Arnulf Hölscher1, Christian Gutschow2, Henner Schmidt2, Santiago Horgan3, Marc Bludau1, Wolfgang Schröder1, Jessica Leers1
1Surgery, University of Cologne, Koeln, Germany; 2Surgery, University of Zurich, Zurich, Switzerland; 3Surgery, University of California, San Diego, CA
Background: Gastro-esophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition due to the loss of the lower esophageal sphincter and other anatomical alterations. Despite a routine prescription of proton-pump inhibitors reflux-associated mucosal damage in the remnant esophagus is frequently observed. This study focuses on macroscopic and microscopic mucosal damages in the esophageal remnant in a long-term follow-up. Additionally the prevalence of mucosal damage is compared between the subgroups of esophageal squamous cell- and adenocarcinoma.
Methods: All patients undergoing esophagectomy are prospectively entered in our IRB approved database. All patients undergo a routine check-up program with yearly surveillance endoscopies following esophagectomy. Only patients with a complete follow-up of more than 5 years and a complete check-up program were included into this study. Macroscopic and histologic mucosal changes of the remnant esophagus were analyzed in a yearly interval.
Results: The study group is made up by 50 patients meeting the inclusion criteria, consisting of 31 adenocarcinomas (AC) and 19 squamous cell carcinomas (SCC). Mucosal damage was already seen 1 year after surgery in 20 patients macroscopically (43%) and in 21 patients microscopically (45%). In the 5-year follow-up the prevalence for macroscopic and microscopic damage was 55% and 60%, respectively. The prevalence of mucosal damage was higher in AC patients than in SCC patients (1y-FU: 51% [AC] vs 28% [SCC]; 5y-FU: 68% [AC] vs 35% [SCC], p<.05). Newly acquired Barrett esophagus were seen in 7 patients (14%) with two patients (24%) showing histologic proof of neoplasia.
Conclusion: This study shows an already high prevalence of reflux-associated mucosal damage in the remnant esophagus one year out of surgery and only a moderate increase in prevelance in the following years. Mucosal damage was more frequently seen in AC patients and the occurrence of neoplastic tissue in de-novo Barrett esophagus was high (29%). Endoscopic surveillance with targeted biopsies seems to be an indispensable tool to follow patients after esophagectomy appropriately.
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