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When Does Barrett’s Esophagus Require Surgery?
Dr. Miller: You have Barrett's Esophagus? When do you need surgery, or do you even need surgery?
We're here today with Dr. Courtney Scaife and she's a Professor of Surgery here in the Department of Surgery at the University of Utah. She also specializes in cancer surgery. Courtney, tell us a little about a patient who might need surgery on the esophagus. I understand that patients with Barrett's Esophagus mostly don't need surgery, but there are times when they do. When would that time be?
Dr. Scaife: Patients who have Barrett's Esophagus are usually managed by gastroenterologists. And they're well managed with oral medications or sometimes requiring interventional procedures. But if that Barrett's progresses to high-grade dysplasia or an invasive cancer, high-grade dysplasia is a pre-cancer change to the cells in the esophagus. So if a patient has pre-cancerous changes that can't be managed by the gastroenterologist's limited interventions, meaning limited intervention to the esophagus or they've regressed to full cancer, those patients do need surgery of the esophagus.
Dr. Miller: Now, that's not typically common in Barrett's but it does occur.
Dr. Scaife: That's correct, it's uncommon.
Dr. Miller: So by the time the patient gets to you, they usually have advanced Barrett's or adenocarcinoma of the esophagus that isn't remedial by any of the topical treatments that the gastroenterologists use.
Dr. Scaife: That's correct.
Treating Advanced Esophageal Cancer: Pre-Treatment and Surgery
Dr. Miller: And so what do you tell the patient initially and what can they expect undergoing surgery?
Dr. Scaife: The first thing that is important to evaluate is if they progressed to cancer, but it's a very early stage, they need the surgery we're talking about. If they have a slightly later stage or more advanced cancer, we routinely treat those patients with radiation and chemotherapy before surgery. There are actually two types of cancer of the esophagus, two different cellular types. And one is more likely caused by smoking, the other is the kind, adenocarcinoma that is related to Barrett's and chronic reflux. We treat that in more advanced stages with neoadjuvant, meaning treating the patient with chemotherapy and radiation before surgery. Therapy.
Dr. Miller: Patients can develop Barrett's Esophagus after many years of esophageal reflux or acid reflux, otherwise known as heartburn. And so if you have heartburn and you've had it for five years or over the age of 50, you should see your primary care physician to have that treated and possibly looked at by a gastroenterologist.
Dr. Scaife: Yes, we agree. Screening in patients who have chronic reflux is important to identify Barrett's and to monitor that Barrett's does not progress to those pre-cancerous or cancer changes.
Esophagectomy: Replacing the Esophagus with the Stomach
Dr. Miller: Now, removing the esophagus, otherwise known as an esophagectomy, sounds like a pretty big surgery. What would a patient expect, following that?
Dr. Scaife: It is a big surgery and, unfortunately, there are several different ways to do the operation. The operation can be done through the abdomen and the neck, it can be done through the abdomen and the chest, or it can be done through the abdomen, the chest, and the neck. And then minimally invasive techniques can be added as well. And so many surgeons use different techniques. But really there's no data that shows that either approach is different. You want the surgeon to do the operation that they are most comfortable with and that they do that operation most frequently. But with all of the techniques of the operation, the outcomes are effectively the same.
Dr. Miller: Does it at all depend on the type of patient? Their size, their body physiology? Does that sway you in terms of the type of surgery that you do if their large, small, or . . .
Dr. Scaife: Usually not. There may be some unusual cases where that influences the decision, but usually not. When we do esophagus surgery, we don't just take out a piece of the esophagus. Particularly in this case because it's for cancer. So we need a wide margin around the cancer. So effectively the patient's entire esophagus is removed. So in that approach, and the reason that all of those approaches included an abdominal portion of the surgery, is that we need to choose a part of the abdomen, another part of the intestinal tract to replace the esophagus.
Dr. Miller: So it's like a graft.
Dr. Scaife: That's exactly right. So the choices most commonly are the stomach, a piece of the small intestine, or the piece of the colon.
Dr. Miller: Do you need to use the whole stomach or part of it?
Dr. Scaife: Yes, so in order to get the stomach to reach up into the neck, to reach where you're replacing the esophagus, it's as though they've had a stomach removal or almost like a gastric bypass surgery. So their stomach is made to be a very narrow tube and pulled up into their chest so effectively they don't have a reservoir to store their meal. And so patients eat four to six frequent small meals a day instead of eating Thanksgiving dinner.
Dr. Miller: And so do they tend to lose weight in the long run?
Dr. Scaife: Fortunately, we're able to train patients to eat really well. The majority of patients that we operate on, have so many symptoms before surgery that they admit they've been eating that way before surgery. So most patients do not lose weight and actually do well after surgery.
Types of Esophageal Cancer and Their Impact on Treatment
Dr. Miller: Now, Courtney, you mentioned that there are two types of cancers encountered in esophageal cancers, and I think one is above and one is below. Does that affect the type of operation that you do?
Dr. Scaife: It does. If we frequently . . . squamous cell carcinoma, we've been mostly talking about adenocarcinoma of the esophagus.
Dr. Miller: Squamous cells are more associated with smoking and alcohol.
Dr. Scaife: That's right. So Squamous cell carcinoma more associated with smoking is frequently more in the more proximal, closer to your mouth part of the esophagus. Sometimes that can be treated with chemotherapy and radiation only. If it persists after the chemotherapy and radiation, we do an esophagectomy. And often that procedure necessitates opening the chest to get an appropriate section of the higher part of the esophagus.
Monitoring and Prevention of Esophageal Cancer
Dr. Miller: Now, following a successful surgery, I imagine that one needs to go back in and look from time to time to make sure there are no complications. Is that true?
Dr. Scaife: We ask patients in their frequent clinic visits which, at minimum, are every six months, if patients are having symptoms with swallowing, symptoms with eating, weight loss, or weight gain as you've mentioned, diarrhea, but most commonly, it's difficulties with swallowing or weight loss. If those patients have symptoms, we refer them to a gastroenterologist for an endoscopy to evaluate the graft that we used to replace the esophagus.
Dr. Miller: So it sounds like the best way to keep from ending up in the office of the surgeon is to avoid smoking altogether, to drink minimally if you drink at all. And also, if you have acid reflux and are over the age of 50, have that looked at.
Dr. Scaife: That's exactly right. We recommend that if you have long-term reflux, have at least one screening and then follow up based on the recommendations of your gastroenterologist.
updated: November 19, 2024
originally published: September 22, 2015