Once a rare tumor, adenocarcinoma of the esophagus is currently the cancer with the fastest-rising incidence in America. Recent data indicate that in the United States since 1975, the rate of increase of adenocarcinoma of the esophagus has outpaced the next closest cancer, melanoma, by nearly 3 times, and most other cancers by >6 times.^4,16,24 The current average yearly increase in incidence in the United States exceeds 20%, but among white males the incidence has increased >800% since the mid-1970s in some areas of the country.^5,11,17 These are alarming statistics, and this increase has propelled this tumor into one of the top 15 cancers in U.S. white males. Further, this increase has led to a complete epidemiologic shift such that in the United States and other industrialized countries adenocarcinoma has replaced squamous cell as the most common esophageal malignancy.^8,11,24.

There is also now clear evidence that the prevalence of the precursor lesion for esophageal adenocarcinoma, Barrett’s esophagus, is also increasing. Recently van Soest and colleagues reported that, adjusted for the number of endoscopies, the incidence of Barrett’s doubled within the general population of the Netherlands from 1997 to 2002.²⁸ In addition to the increasing prevalence of the disease, widespread acceptance of the importance of surveillance endoscopy in patients with Barrett’s has led to the identification of increasing numbers of patients with progression of their Barrett’s to high-grade dysplasia or intramucosal adenocarcinoma. These lesions, while potentially lethal, are curable in most patients. Traditional therapy for these patients has been an esophagectomy.^22,25,26

Since patients with high-grade dysplasia or intramucosal adenocarcinoma are expected to be cured with an esophageal resection, procedure-related morbidity and mortality along with postoperative quality of life are important issues. Recent series have shown that the mortality from esophagectomy in patients with high-grade dysplasia is much lower (≤1%) than the widely quoted 5% to 10% rate for patients with dysphagia, weight loss, and large tumors that were the norm previously.^7,13 Along with reduced mortality there are ongoing efforts to reduce morbidity and improve quality of life in these patients with these curable lesions. Traditional esophagectomy is associated with a vagotomy and pyloroplasty, and some patients have problems postoperatively with dumping and diarrhea. In response to these issues, the author’s group uses a vagal-sparing technique for patients with high-grade dysplasia or early esophageal adenocarcinoma. This operation preserves the vagal innervation to the pylorus and the remaining gastrointestinal tract and is associated with reduced morbidity, including avoidance of postvagotomy dumping and diarrhea, while maintaining the advantages of complete removal of the diseased esophagus, including the Barrett’s epithelium.² In a recent update of experience with vagal-sparing esophagectomy for Barrett’s and intramucosal adenocarcinoma, the author and his colleagues again confirmed that preservation of the vagal nerves is feasible during esophagectomy and is associated with reduced morbidity. Specifically, infectious, respiratory, and anastomotic complications were all reduced in patients who had a vagal-sparing compared to a transhiatal esophagectomy.²³ To further reduce morbidity, many centers now offer a minimally invasive esophagectomy.

An important issue in regard to minimizing morbidity and improving quality of life in patients with high-grade dysplasia or intramucosal adenocarcinoma is to ensure that outcome and survival are not compromised by scaling back the extent of the operation. The author reviewed his institution’s experience with three types of esophagectomy (transthoracic en bloc, transhiatal, and vagal sparing) in 85 patients with intramucosal adenocarcinoma of the esophagus. The importance of this comparison is that while each operation removes the diseased esophagus, there is a substantial difference in the lymphadenectomy that accompanies each approach. In particular, no formal node dissection accompanies a vagal-sparing esophagectomy, and typically none or only a few nodes are removed. The results confirmed that cancer-related survival is excellent in these patients (95% at 5 years) and is independent of the type of resection and extent of lymphadenectomy.²³ The reason a lymph node dissection is not important for survival with intramucosal adenocarcinoma is that the prevalence of node metastases with this tumor is small, around 4%. However, once the tumor penetrates into the submucosa, the risk of one or more node metastases increases to ≥30%, and therapies that do not address potential lymph node metastases are inappropriate.⁹

Local/regional staging of esophageal adenocarcinoma is best done with endoscopic ultrasound. Standard 7.5- and 12-MHz endoscopic ultrasound probes can accurately assess the depth of invasion once the tumor has gone through the submucosa and also
provide information on the presence of abnormal or enlarged lymph nodes. However, neither the standard probes nor newer high-resolution 20-MHz probes are able to accurately distinguish intramucosal from submucosal tumor invasion.^5,14,15,19 This distinction is critical, because the likelihood of lymph node metastases increases significantly once a tumor breaches the muscularis mucosa and enters the submucosa.²¹ This clinical problem led us to begin using endoscopic mucosal resection (EMR) to precisely determine the depth of invasion of early esophageal adenocarcinomas in order to determine the appropriateness of a vagal-sparing esophagectomy.¹⁸ After gaining comfort with EMR, the author’s group now uses it to remove nodules and small tumors prior to Barrett’s ablation in some patients in an effort to preserve the esophagus, either secondary to significant medical comorbidities that would preclude esophagectomy or because of limited lengths of Barrett’s in otherwise healthy individuals as an option instead of esophagectomy.

Endoscopic mucosal resection excises a disc of esophageal wall down to the muscularis propria and provides a specimen for histologic review that includes both mucosa and submucosa. Thus, from an EMR specimen, a pathologist can accurately determine whether a tumor is limited to the mucosa or has penetrated beyond the muscularis mucosa into the submucosa. Although several techniques have been proposed for EMR, one commonly used method involves the use of a cap that fits over the end of a standard endoscope. Developed by Inoue and colleagues from Japan, these caps are available in various sizes and configurations (flat versus angled), and come with a complete kit for the procedure by Olympus.²⁷ EMR can be performed with conscious sedation, but general anesthesia with the patient intubated in the operating room will minimize the chance of aspiration. The procedure is quick, and patients are typically discharged home a few hours later. Using the large cap for EMR, lesions ≤1.5 cm in size can be excised in one piece. However, piecemeal excision of a lesion is also acceptable. If the EMR is only done for staging and a surgical resection is planned, then the EMR resection margins are not important; as long as an adequate portion of the tumor has been excised to allow assessment of the depth of invasion, no further efforts at excision are necessary. Using this technique, EMR accurately determined the depth of tumor invasion in all cases and had completely excised the target lesion in 86% of patients.¹⁸