Ann Thorac Surg 2008;85:S760-S763. doi:10.1016/j.athoracsur.2007.12.002
© 2008 The Society of Thoracic Surgeons
Supplement: The Minimally Invasive Thoracic Surgery Summit
How to Keep the Treatment of Esophageal Disease in the Surgeon’s Hands
James D. Luketich, MD*,
Arjun Pennathur, MD
The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
* Address correspondence to Dr Luketich, The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-800, Pittsburgh, PA 15213–3221 (Email: luketichjd{at}upmc.edu).
Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.
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Introduction
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Disorders of the esophagus span a wide spectrum of diseases from gastroesophageal reflux disease (GERD) to motility disorders such as achalasia to esophageal cancer. The management of these disorders varies considerably from medical treatment in uncomplicated GERD to esophagectomy in esophageal cancer. In addition, several endoscopic therapies are emerging in the management of not only benign disorders but also malignant diseases of the esophagus [1, 2]. It is critical that the esophageal surgeon practice disease-based therapy. Specifically, the surgeon should not only be familiar with, but actually perform diagnostic testing, medical management, and endoscopic therapeutic interventions in addition to surgery for the broad spectrum of esophageal disorders.
The current era is a critical time for esophageal surgeons for several reasons. For example, the incidence of esophageal carcinoma has increased dramatically over the past three decades (Fig 1), and the number of patients with GERD seeking alternatives to medical therapy is increasing. Thus, the pool of patients with esophageal disorders needing interventions is expanding [3].
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Fig 1. The incidence of squamous cell carcinoma (black males, filled squares; white males, open squares) and adenocarcinoma (black males, filled circles; white males, open circles). (Reprinted with permission from Devea SS, Blot WJ, Fraumeni JF. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 1998,83:2049–53. Copyright 1998 American Cancer Society. This material is reproduced with the permission of Wiley-Liss, Inc, a subsidiary of John Wiley & Sons, Inc.)
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Recently, new technologies such as endoscopic mucosal resection (EMR), expandable metal stents, photodynamic therapy (PDT), and endoscopic GERD interventions are being performed in increasing numbers, in many institutions by non-surgeons [2, 4–7]. Some of these therapies have directly impacted the esophageal surgeons practice. For example, many patients with esophageal cancer present with advanced disease for which palliative surgical esophageal bypass was performed. Now, with the success of expandable metal stents or PDT for this problem, surgery is rarely indicated for this group of patients. At the other end of the disease spectrum, lies Barrett’s esophagus, with and without high-grade dysplasia (HGD) and early stage cancer picked up during surveillance. While these patients may represent a group of patients most likely to be cured by esophagectomy, endoscopic therapies such as endoscopic mucosal resection (EMR), and mucosal ablative therapies including photodynamic therapy and radiofrequency ablation (Barrx Medical, Sunnyvale, California) are being used increasingly as primary treatment even in medically operable patients with Barrett’s or early stage cancer due to the concerns over the morbidity and mortality of esophagectomy. It is clear that if the thoracic surgeon hopes to play a role in the management of esophageal cancer he/she must learn to perform the non-operative endoscopic therapies for both the inoperable patient with late disease and the patient with high-grade dysplasia and early cancer.
In addition, the last decade has seen a rise in the number of patients with GERD seeking alternatives to medical therapy such as laparoscopic anti-reflux procedures. Thoracic surgeons in some centers are prepared to manage the more complex esophageal problems such as redo-antireflux surgery, and recurrent giant paraesophageal hernias and many perform these via open surgical approaches after the patient has failed laparoscopic attempts at repair. However, few thoracic surgeons are experienced in routine laparoscopic anti-reflux surgery and hence are not seeing the patients for their first procedure but only are referred after failing their initial surgery. Now, a new wave of endoscopic therapies for GERD and Barrett’s esophagus are about to be unleashed, and it is primarily the gastroenterologists and general surgeons that are leading the way in investigating and implementing these new approaches. This approach by many thoracic surgeons as the end of the line clinician is contrary to a disease-based approach and leaves the thoracic surgeon out of the loop in terms of the early management, referral patterns and decision making in patients with esophageal disorders. Thoracic surgeons should be prepared to manage these complex redo patients but more importantly we need to provide training in our residencies to provide our specialty with the full armamentarium of management options including diagnostics, minimally invasive and endoscopic modalities to manage all esophageal problems. In order to gain expertise in all phases of esophageal disease management, it is becoming clear that thoracic streamed residency programs or advanced fellowship training is advisable.
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Potentially Resectable Patients with Esophageal Cancer
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Surgical resection is the primary curative therapy for patients with resectable esophageal cancer. The surgeon should not be limited to performing the esophagectomy alone. It is important for the surgeon to lead the effort in the initial evaluation and staging as well as provide an overall multidisciplinary oversight in the management of the patient. Optimal results are obtained by accurate staging, risk assessment, patient selection, and choosing an appropriate approach in the surgical management of these patients. If indicated, the surgeon should also coordinate neoadjuvant and adjuvant therapies used in the treatment of these patients.
Each of these aspects is critical for the surgeon. For example, accurate staging is important for clear stratification of patients and decisions about their treatment [8]. The surgeon should actively participate in the staging procedures such as esophagogastroduodenoscopy, endoscopic ultrasound, EMR, and minimally invasive surgical staging [8, 9]. Accurate staging would allow the surgeon to clearly stage these patients, develop protocols for enrollment in clinical trials, and adopt a multimodality approach in patients with resectable esophageal cancer.
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Management of High-Risk Patients With Potentially Resectable Disease
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We occasionally encounter high-risk patients who have localized disease and are potentially resectable but who are not operable because of significant associated comorbidities. In these patients, other nonoperative endoscopic therapies such as PDT and EMR may be applicable, particularly in those who have high-grade dysplasia or intramucosal T1 neoplasm. Further, these therapies are being proposed as primary treatment even in operable patients. It is important that the surgeon participate in the management of these patients even when they are high-risk patients who are not fit for esophagectomy.
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Photodynamic Therapy
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Photodynamic therapy has been used alone or in combination with neodymium yttrium aluminium garnet (Nd:YAG) laser therapy or EMR [2, 10–12]. In one of the large series, Overholt and colleagues [12] presented their long term follow-up in 103 patients (80 patients with high-grade dysplasia, 14 with low-grade dysplasia, and 9 with early-stage cancer) where PDT was used as the primary treatment, but most also received Nd:YAG laser therapy to residual areas of Barrett’s esophagus [12]. The primary end point for the study was defined as elimination of dysplasia or cancer, and treatment failure was defined as persistence of dysplasia or progression of disease. At a mean follow-up of 50.7 months, intention to treat analysis of the success rate was 92.9% for low-grade dysplasia, 77.5% for high-grade dysplasia, and 44.4% early-stage carcinoma groups. We have also reported our results of PDT for the treatment of 50 nonoperative high-risk patients with high-grade dysplasia or esophageal cancer performed by thoracic surgeons [10]. Although, the results were inferior to surgical resection, PDT may play a role in these high-risk patients. Importantly, thoracic surgeons who routinely use PDT in their practice for palliation maintain their role as the gate keeper and decision maker and then can determine who should receive PDT or stents for palliation, potential curative therapy for HGD or early stage cancer in the non-surgical patient, etc.
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Endoscopic Mucosal Resection
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Endoscopic mucosal resection has been used in Japan for early gastric neoplasms, and is now being used for the treatment of high-grade dysplasia and early esophageal cancer. A recent study by Ell and colleagues [2] reported the results of EMR in 100 highly selected patients with T1 intramucosal cancers. In 49% of patients, argon plasma coagulation or PDT with 5-aminolevulinic acid was also used. The lateral margins of resection were positive in 34% of patients and could not be assessed in 33%. During follow-up, recurrent or metachronous lesions were detected in 11% of patients. The estimated overall survival at 3 years was 98%. Despite a high rate of positive margins and local recurrence rates, the results of survival appear encouraging in this highly selected group of patients. The role of EMR/PDT in the management of high-grade dysplasia or T1 intramucosal lesions is evolving, and it is important that thoracic surgeons learn these new endoscopic therapies and critically evaluate these modalities in selected patients.
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Palliative Management of Esophageal Cancer
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Many patients with esophageal cancer tend to present late in the disease course with symptoms of dysphagia and malnutrition and may require palliation of their symptoms. The surgeon should not be limited to resectable patients alone and should also participate in the palliative management of advanced-stage disease. An example of how not to manage a patient with advanced disease: If the surgeon’s office is called about a 70-year-old man with esophageal cancer and liver metastases, the response should not be to refer this patient immediately to oncology without even seeing the patient. It is critical that the surgeon evaluates all patients with esophageal cancer and becomes the gatekeeper. The surgeon should see and evaluate the patient, participate in the management, and make the calls and the referrals. In some cases, these patients have been labeled as having metastatic disease, but may have a cystic benign lesion. Familiarity with the medical and radiation options are critical and will lead to a more robust referral pattern if the thoracic surgeon is willing to evaluate all patients. This may include simple decisions about when to give chemotherapy and when to consider hospice and simple quality of life issues or to palliate the dysphagia which may lead to a rebound in the patient’s performance status and then be eligible for chemotherapy or a clinical trial. These are important considerations for thoracic surgeons and their patients with esophageal cancer. It is important to develop a disease-based practice.
Surgical bypass may be rarely indicated in these patients, but effective palliation can be obtained by endoscopic methods in many patients. Photodynamic therapy can offer an effective palliation in patients with obstructing esophageal cancer [13, 14]; however, in some patients, reintervention and a multimodality approach are required to maintain palliation. Esophageal stents have also been successfully used to relieve dysphagia in many of these patients. In our early experience with self-expanding metal stents in 100 consecutive patients [6], we found we could improve dysphagia significantly with little morbidity. Having multiple options, including PDT for palliation allows the surgeon to tailor the intervention to what is best suited for each patient. These modalities of treatment can be a useful addition to the armamentarium of the surgeon for the palliation of esophageal neoplasm.
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Academic Impact
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The broad practice in the management of esophageal diseases has had a significant academic impact. We have conducted numerous clinical trials and educational courses at University of Pittsburgh Medical Center, and over 100 thoracic residents, surgeons, and fellows have been trained in these techniques. The faculty has presented several papers in scientific meetings. In addition, these efforts have led to significant research funding [4–6, 7, 10, 11, 13, 14].
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Role of the Surgeon in Benign Disease
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The surgeon should participate in the initial evaluation of the patient with benign disease. It is very helpful to work in a collaborative fashion with gastroenterology colleagues in the evaluation of these patients. Similar to malignant diseases, it is important to participate in the diagnostic testing of these patients. These include endoscopy and esophageal function testing. Both esophageal manometry and 24-hour pH testing are useful investigations in many patients with benign esophageal disease, and it is important that the surgeon actively participates in these investigations. In addition, surgeons should collaborate with gastroenterology in Barrett’s esophagus surveillance programs. In our experience, the ideal thoracic service collaborates actively with the gastroenterology colleagues in the esophageal diagnostic testing program and in the management of these patients.
The surgical management of reflux disease has undergone a profound change in the last 1 to 2 decades, with a shift from an open approach to a laparoscopic approach for repair of a full spectrum of benign diseases ranging from GERD to motility disorders such as achalasia. In addition, there are several emerging endoscopic techniques for reflux disease, such as Stretta (Curon Medical, Sunnyvale, CA) or plicating gastric folds (NDO Plicator, NDO Surgical, Mansfield, MA) [1]. Not all these technologies will be successful or produce ideal results; therefore, it is important for the surgeon to critically evaluate these technologies. For example, thoracic surgeons at our institution obtained training in Stretta but did not proceed with this technology after initial evaluation because of suboptimal results. Similarly, thoracic surgeons should learn and practice minimally invasive techniques to have the full armamentarium available in the management of these patients. These techniques are particularly valuable in the management of a wide spectrum or benign esophageal disorders [15–17].
An example of an evolving approach is the transoral stapling in management of Zenkers’ diverticulum. We recently reported our experience in 47 patients with large Zenkers’ diverticulum. Endoscopic stapling was attempted in 28 patients [18], and the remaining underwent open myotomy with diverticulopexy. The operating room times were shorter; the length of stay was not significantly different. Dysphagia significantly improved in both groups during follow-up, and we are currently evaluating longer-term outcomes.
In summary, it is important for the surgeon to not only participate in the diagnostic aspects of benign esophageal disease but also to learn and evaluate emerging technologies in their treatment. It is also critical for us to learn and perform advanced minimally invasive procedures. The spectrum of esophageal disorders is wide, with several benign and malignant diseases, and the surgeon can play a broad role in the management of esophageal diseases. The introduction of new technology should not change the paradigm of who treats esophageal disorders. Surgeons must practice disease-based therapy and learn and add to their armamentarium a wide range of emerging minimally invasive and endoscopic therapies. These will then be beneficial for our patients, who will then have multiple options. An active esophageal practice is an excellent opportunity for basic and clinical research, and the academic potential is unlimited.
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References
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- Ozawa S, Yoshida M, Kumai K, et al. New endoscopic treatments for gastroesophageal reflux disease Ann Thorac Cardiovasc Surg 2005;11:146-153.[Medline]
- Ell C, May A, Pech O, et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer) Gastrointest Endosc 2007;65:3-10.[Medline]
- Erzinger PC, Mayer RJ. Esophageal cancer N Engl J Med 2004;349:2241-2252.
- Luketich J, Christie N, Buenaventura P, Weigel T, Keenan R, Nguyen N. Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period Surg Endosc 2000;14:653-657.[Medline]
- Litle V, Luketich J, Christie N, et al. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients Ann Thorac Surg 2003;76:1687-1693.[Abstract/Free Full Text]
- Christie NA, Buenaventura PO, Fernando HC, et al. Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up Ann Thorac Surg 2001;71:1797-1801discussion 1801–2.[Abstract/Free Full Text]
- Pennathur A, Chang AC, McGrath KM, et al. Polyflex expandable stents in the treatment of esophageal disease. Presented at Society of Thoracic Surgeons Annual Meeting, San Diego, CA, Jan 29–31, 2007.
- Krasna MJ, Reed CE, Nedzwiecki, et al. CALGB 9380: A prospective trial of the feasibility of throacoscopy/laproscopy in staging esophageal cancer Ann Thorac Surg 2001;71:1073-1079.[Abstract/Free Full Text]
- Maish MS, DeMeester SR. Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma Ann Thorac Surg 2004;78:1777-1782.[Abstract/Free Full Text]
- Keeley SB, Pennathur A, Gooding W, et al. Photodynamic therapy with curative intent for Barrett’s esophagus with high grade dysplasia and superficial esophageal cancer Ann Surg Oncol 2007;14:2406-2410.[Medline]
- Abbas G, Pennathur A, Keeley SB, Landreneau RJ, Luketich JD. Laser ablation therapies for Barrett’s esophagus Semin Thorac Cardiovasc Surg 2005;17:313-319.[Medline]
- Overholt BF, Panjehpour M, Halber DL. Photodynamic therapy for Barrett’s esophagus with dysplasia and/or early stage carcinoma: long-term results Gastrointest Endosc 2003;58:183-188.[Medline]
- Chen M, Pennathur A, Luketich JD. The role of photodynamic therapy in unresectable esophageal and lung cancer Lasers Surg Medicine 2006;38:396-402.
- Litle V, Luketich J, Christie N, et al. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients Ann Thorac Surg 2003;76:1687-1693.[Abstract/Free Full Text]
- Pierre AF, Luketich JD, Fernando HC, et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients Ann Thorac Surg 2002;74:1909-1915discussion 1915–6.[Abstract/Free Full Text]
- Schuchert MJ, Luketich JD, Landreneau RJ, et al. The effect of pre-operative interventions on surgical outcome in patients with achalasia. Presentation at Southern Thoracic Surgical Association, Tucson, AZ, Nov 9–11, 2006.
- Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally invasive reoperation for gastroesophageal reflux disease Ann Thorac Surg 2002;74:328-331discussion 331–2.[Abstract/Free Full Text]
- Morse CR, Fernando HC, Ferson PF, Landreneau RJ, Luketich JD. Preliminary Experience by a thoracic service with endoscopic transoral stapling of cervical (Zenker’s) diverticulum J Gastrointest Surg 2007;11:1091-1094.[Medline]
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Introduction
Potentially Resectable Patients...