Purpose: Adenocarcinoma of the distal esophagus arising in the background of intestinal metaplasia (IM) is commonly treated with an Ivor-Lewis esophagectomy (ILE) in which esophagectomy, proximal gastrectomy and pyloromyotomy is performed. The latter can lead to worsened reflux, especially with bile that would continue to potentiate tissue injury in the post-surgical esophagus. In this setting, if there is any post-op remnant segment of IM, it could potentially develop dysplasia or adenocarcinoma (EAC). We studied this outcome in patients who underwent incomplete ILE at our institution.
Methods: Three cases with incomplete ILE were identified and are described below.
Results:Patient 1: 73 year-old man with 20 year h/o gastro-esophageal reflux disease (GERD) underwent an ILE for T2N0M0 EAC in the setting of IM; 4 cm IM remnant was left behind. Two years later, an EGD showed high-grade dysplasia (HGD) for which he underwent photodynamic therapy (PDT). Subsequently, he underwent 2 radiofrequency ablations (RFA) with no residual dysplasia. Eight months later, he developed a Barrett's nodule with pathology showing moderately differentiated adenocarcinoma, removed using endoscopic mucosal resection. Patient 2: 70 year-old man with 30 year h/o GERD was diagnosed with well-differentiated distal EAC and underwent an ILE. One year later, a surveillance EGD revealed 7 cm remnant IM with HGD and foci of EAC. He underwent PDT twice with only IM remaining afterwards. Five years later, he had RFA twice for LGD and 2 years after that, an EGD only revealed IM without dysplasia. Patient 3: 50 year-old man with 20 year h/o GERD and intermittent dysphagia had an EGD that showed a proximal stricture; biopsies showed HGD and focal EAC staged as T1N0M0. An ILE was performed but proximal margin could not be resected. He had cancer in the 5 cm remnant. Despite RFAx2, a surveillance EGD showed persistence of cancer 8 months after ILE in this relatively young man and required total esophagectomy with jejunal reconstruction.
Conclusion: Patients with Barrett's cancer need a multidisciplinary approach by gastroenterologists, surgeons and gastrointestinal pathologists prior to ILE to clearly document upper and lower margins of IM and malignancy and surgeons should strive to obtain IM-free margins to prevent any post-op recurrence of neoplasia.