Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
 Esophagus

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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Dysplasia
 

Does surgical mucosectomy plus antireflux surgery represent a good strategy?

T. Kawano, M. Endo (Tokyo)

Recently, Barrett's esophagus has been highlighted because it presents a high potential risk of esophageal adenocarcinoma. Currently, various therapeutic modalities for Barrett's related neoplasms have been under discussion. Although the most appropriate therapeutic strategy for Barrett's esophagus representing severe dysplasia is now controversial, we think that if a superficial carcinoma or high-grade dysplasia is detected in a patient with Barrett's esophagus, the lesion should be treated. The question is "Does surgical mucosectomy plus antireflux surgery represent a good strategy?" and the answer is "No".

Surgical mucosectomy is indicated only for lesions located strictly in the superficial esophagus without metastasis and requires laparotomy or thoracotomy to accomplish its therapeutic purpose. The technique of surgical mucosectomy may be complicated, invasive and is not easy. Therefore, surgical mucosectomy plus antireflux surgery requires not only an extremely high level of diagnostic accuracy, but also a high level of surgical skill. On the other hand, we now have useful techniques for endoscopic mucosectomy and the endoscopic procedure is minimally invasive, safe and easy.

Barrett’s epithelium develops upward from the gastroesophageal junction (GEJ) and endoscopic mucosectomy for lesions in the GEJ is relatively difficult because the GEJ is a physiologically constrictive region. We have devised new techniques for mucosectomy with negative pressure (suction) called np-EEM (endoscopic esophageal mucosectomy with negative pressure using a transparent overtube) and EMRC (endoscopic mucosal resection using a cap-fitted panendoscope) for early esophageal cancers [1-3]. With the np-EEM technique, it is not difficult to perform endoscopic mucosectomy in the GEJ and cervical esophagus as well [2, 4]. Based on our experience with 140 patients with esophageal diseases receiving endoscopic mucosectomy by the np-EEM technique, no serious complications have been seen (Table I). Now, mucosal tumors are a good indication for mucosectomy, and superficial submucosal tumors without clinical metastasis are also indicated for endoscopic mucosectomy in terms of step-up therapy [5, 6].

Although we have only 18 cases of endoscopic mucosectomy in or near the GEJ, we believe the application of np-EEM plus proton pump inhibitor medication for patients with Barrett's related neoplasms offers greater advantages to patients than surgical mucosectomy plus antireflux surgery. If the endoscopic procedure is technically difficult for a superficial neoplastic lesion in Barrett's esophagus, esophagectomy with reconstruction may be recommended because of its reliability.

Table I.

References

1. Kawano T, Miyake S, Yasuno M, et al. A new technique for endoscopic esophageal mucosectomy using a transparent overtube with intraluminal negative pressure. Dig Endosc 1991;3:159-167.

2. Kawano T, Endo M. A new multipurpose tube for esophageal endoscopy. Endoscopy 1997;29:526-527.

3. Inoue H, Endo M, Takeshita K, et al. Endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Gastroent Endosc 1992;34:2387-2390 (in Japanese with English abstract).

4. Kawano T, Endo M. Is there a place for endoscopic mucosectomy in early cancers of the cardia or EGJ? In: Giuli R, Galmiche JP, Jamieson GC, Scarpignato C, eds. The esophagogastric junction. Paris: John Libbey Eurotext, 1998:12041206.

5. Endo M, Yoshino K, Kawano T, et al. Clinicopathologic analysis of lymph node metastasis in surgically resected superficial cancer of the thoracic esophagus. Dis Esophagus 2000;13:125-129.

6. Kawano T, Nagai K, Inoue H, et al. Step up strategy in the treatment for superficial esophageal cancer. In: Bismuth H, Galmiche JP, Huguier M, Jaeck D, eds.The International Gastro-surgical Club. Rome: Monduzzi Editore, 1998:23-26.


Publication date: August 2003 OESO©2015