Esophagectomy Outcomes in the Endoscopic Mucosal Resection Era

Endoscopic mucosal resection (EMR) and esophagectomy are treatment options for cT1 esophageal adenocarcinoma. Our aim was to study outcomes for patients undergoing EMR then esophagectomy.

We identified patients undergoing EMR and esophagectomy for cT1 esophageal adenocarcinoma over 10 years. EMR histology was used to predict nodal involvement with a risk-scoring tool. Patient demographics, surgical techniques, pathology, postoperative outcomes, and survival were recorded.

Of 1,092 that esophagectomies were performed, 51 patients underwent EMR and esophagectomy for cT1 esophageal adenocarcinoma. The mean time between EMR and esophagectomy was 4 (SD,8.0) months. According to the risk-scoring tool based on EMR histology, 1 patient was low risk, 13 (25%) were at moderate risk, and 37 (73%) were at high risk for lymph node metastasis. The time between EMR and the surgical intervention was longer and more patients had multiple EMRs in the moderate-risk group (9 vs 1.4 months, p = 0.03) compared with the high-risk group (38% vs 11% patients, p = 0.04). Operative mortality was 4% and morbidity was 43%. Pneumonia occurred in 3 of 51 patients (6%), atrial fibrillation in 4 (8%), and clinical anastomotic leak in 6 (12%). Of the 51 patients, 14 (27%) were upstaged after esophagectomy. Nodal involvement was present in 3 of 13 moderate-risk patients (23%) and in 7 of 37 high-risk patients (19%). The 5-year survival was reduced in moderate-risk compared with high-risk patients (54% vs 84%, p = 0.04).

Studying outcomes for cT1 esophageal adenocarcinoma is important. These patients can be divided into those undergoing EMR for staging before esophagectomy and those in whom esophagectomy is a salvage procedure after therapeutic EMRs. Care should be taken to avoid upstaging of patients in the latter group, and we recommend frequent restaging and surveillance to prevent undetected progression of disease. A low threshold for esophagectomy when EMR fails to control disease should be considered.