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Surgery for Barrett's oesophagus

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Surgery for Barrett's oesophagus

What is the role of surgery in Barrett’s Oesophagus?

Oesophagectomy refers to the surgical removal of the oesophagus, and diseased lymph nodes. Lymph nodes are the primary site for the spread of cancerous disease, and are often used to stage the severity of cancer.

In previous years, it was the first-line of treatment for patients with high-grade dysplasia and oesophageal cancer (e.g: intramucosal carcinoma). However, due to the high mortality of 1.2% associated with the procedure, compared with a 0.04% mortality associated with minimally/non-invasive endoscopic procedures it has fallen out of favour as a first-line therapy for the vast majority of patients. Additionally, oesophagectomy is associated with a range of adverse side-effects including respiratory complications, infections, and nerve damage (1).

Oesophagectomy (with resection of lymph nodes) is primarily reserved, nowadays, for patients with cancer that extends beyond the superficial layer of oesophagus, due to the increased risk of metastatic disease (the risk of cancer spreading throughout the body) (2,3). It may also be reserved for patients who were not successfully treated using endoscopic therapies.

Unfortunately, oesophagectomy has a 2-year cure rate of between 78-85%. So post-operative endoscopic surveillance is necessary

There are three main approaches to oesophagectomy:

  • Minimally invasive oesophagectomy
  • Trans-hiatal oesophagectomy
  • Trans-thoracic oesophagectomy

Minimally invasive oesophagectomy involves video-guided laparoscopy(keyhole surgery). The advantages of this procedure are fewer lung-related complications, shorter recovery time and quicker discharges. However, the mortality and morbidity rates are not lower than more invasive procedures.

The other two surgeries are performed by making two cuts to allow access into the patient’s chest. In the trans-hiatal approach, the upper cut is in the neck region and the lower cut is in the abdomen. In the trans-thoracic approach, the upper cut is made in the chest and the lower cut in the abdomen. The oesophagus is then mobilised, the diseased section removed and the stomach is re-joined to the upper part of the oesophagus. Lymph nodes are also removed(4).

The incidence of lung-related complications is lower for the trans-hiatal approach although the survival rate was slightly higher for the trans-thoracic approach at 5-years (39% v.s 27%) (5). Additionally, resection of lymph nodes for staging is not possible via a trans-hiatal approach (6).

Anti-reflux surgery

A surgical option for patients with Barrett’s oesophagus and reflux symptoms that do not respond to medical therapy is anti-reflux surgery (fundoplications). In this treatment, the stomach is wrapped around the lower-end of the oesophagus. This creates a pressure gradient at the end of the oesophagus and prevents reflux of acid from the stomach (7). There is no evidence that anti-reflux surgery is superior to treatment with PPIs in preventing progression of Barrett’s disease to dysplasia or adenocarcinoma (8).

  1. Menon D, Stafinski T, Wu H, Lau D, Wong C. Endoscopic treatments for Barrett’s esophagus: a systematic review of safety and effectiveness compared to esophagectomy. BMC Gastroenterol. 2010;10:111.
  2. Wu J, Pan Y, Wang T, Gao D, Hu B. Endotherapy versus surgery for early neoplasia in Barrett’s esophagus: a meta-analysis. Gastrointest Endosc. 2014 Feb;79(2):233–241.e2.
  3. Bollschweiler E, Baldus SE, Schröder W, Prenzel K, Gutschow C, Schneider PM, et al. High rate of lymph-node metastasis in submucosal esophageal squamous-cell carcinomas and adenocarcinomas. Endoscopy. 2006 Feb;38(2):149–56.
  4. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery [Internet]. Elsevier Health Sciences; 2007. Available from: https://books.google.co.uk/books?id=3kQZfe8SNiYC
  5. Hulscher JBF, van Sandick JW, de Boer AGEM, Wijnhoven BPL, Tijssen JGP, Fockens P, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med [Internet]. 2002 Nov;347(21):1662–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12444180
  6. Wolff CS, Castillo SF, Larson DR, O’Byrne MM, Fredericksen M, Deschamps C, et al. Ivor Lewis approach is superior to transhiatal approach in retrieval of lymph nodes at esophagectomy. Dis Esophagus [Internet]. 2008;21(4):328–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18477255
  7. Wechter D. Anti-reflux surgery. 2015.
  8. Parrilla P, Martínez de Haro LF, Ortiz A, Munitiz V, Molina J, Bermejo J, et al. Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett’s esophagus. Ann Surg [Internet]. 2003 Mar;237(3):291–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12616111