When is surgery indicated in Barrett's (Barrett's esophagus) disease?

Surgical Indications in Barrett's Esophagus

Endoscopic therapy is preferred over surgery for Barrett's esophagus with high-grade dysplasia (HGD) and intramucosal (T1a) adenocarcinoma, while surgical resection is the treatment of choice for submucosal (T1b) adenocarcinoma due to significant risk of lymph node metastasis. 1

Primary Indications for Surgery in Barrett's Esophagus

• Submucosal invasion (T1b): Surgical therapy is considered the treatment of choice for early adenocarcinoma that has extended into submucosa because of the significant risk of lymph node metastasis 1
• High-risk pathologic features: Tumors with poor differentiation, lymphovascular invasion, or deep submucosal invasion (beyond sm1) should undergo surgical resection 1, 2
• Bulky or multinodular tumors: Large or multifocal tumors that cannot be adequately treated with endoscopic methods 2
• Tumors within a long segment of Barrett's esophagus: Extensive Barrett's involvement may be better addressed surgically 2
• Failed endoscopic therapy: When complete eradication cannot be achieved endoscopically 1

Decision-Making Algorithm

1. Initial assessment: All patients with dysplasia or early cancer should be discussed at a specialist multidisciplinary team (MDT) meeting including an interventional endoscopist, upper GI cancer surgeon, radiologist, and GI pathologist 1

2. For High-Grade Dysplasia (HGD):

   • First-line: Barrett's endoscopic therapy (BET) is the preferred treatment 1
   • Surgery consideration only if:
     • Patient preference after informed discussion
     • Extensive disease not amenable to endoscopic treatment
     • Lack of expertise in endoscopic therapy 1

3. For Intramucosal Adenocarcinoma (T1a):

   • BET should be preferred over esophagectomy 1
   • Complete endoscopic resection of all visible abnormalities should be performed 1

4. For Submucosal Adenocarcinoma (T1b):

   • Primary recommendation: Surgical resection with lymphadenectomy 1
   • Exception: BET may be reasonable for T1b with low-risk features (<500μm invasion [sm1], good to moderate differentiation, no lymphatic invasion), especially in poor surgical candidates 1

Surgical Considerations

• Surgical approach: No single technique has proven superiority; options include transhiatal, transthoracic, minimally invasive, or Merendino segmental resection 1
• Volume effect: Surgery should be performed in high-volume centers (minimum 15-20 resections per year) by experienced surgeons to minimize mortality and morbidity 1
• Lymphadenectomy: Should be performed for T1sm tumors due to significant risk of lymph node involvement 1

Comparative Outcomes

• Mortality: Surgical mortality is significantly higher (1.2-5.0%) compared to endoscopic therapy (0.04%) 1
• Morbidity: Surgical complications are more common and severe than with endoscopic therapy 1, 3
• Long-term survival: For early-stage disease treated appropriately, 5-year survival rates can exceed 90% for stage I disease 3
• Quality of life: Endoscopic therapy preserves esophageal function and has better short-term quality of life outcomes 1

Common Pitfalls and Caveats

• Overtreatment: Performing esophagectomy for HGD or T1a disease when endoscopic therapy would be equally effective oncologically with lower morbidity 1
• Undertreatment: Using endoscopic therapy for T1b disease with high-risk features, potentially missing lymph node metastases 1, 2
• Low-volume centers: Surgical mortality rates can exceed 15% in low-volume centers compared to <5% in high-volume centers 1
• Incomplete staging: Failure to accurately determine depth of invasion prior to selecting treatment approach 1
• Patient selection: Not accounting for patient comorbidities and fitness for surgery when making treatment decisions 1, 2

Post-Treatment Surveillance

• After complete eradication with endoscopic therapy, surveillance endoscopy with biopsies should be performed at 3,6, and 12 months and annually thereafter for baseline HGD/esophageal adenocarcinoma 1
• After surgical resection, patients should have the same surveillance strategy as medically treated patients, regardless of the outcome of surgery 1