Chapter 20B

Descriptions of the techniques and reasons for esophageal resections are presented by three leaders in esophageal surgery, working at major, high-volume esophageal centers. A thorough review of the epidemiology (such as is known) and international differences in approaches and outcomes for esophageal cancer treatments is made by Dr Law who points out the ever-increasing differences between the Western and Eastern hemispheres. In the East and Middle East, mid and proximal squamous cell cancers are by far the most prevalent, related to the persistence of carcinogenic environmental exposures. The rapid growth of adenocarcinoma in the West is a more complex issue; at our center, Barrett's esophagus–related cancers now represent 92% of esophageal cancers presenting for treatment. Unfortunately this is not totally related to the decrease in squamous cancers secondary to the decreasing incidence of smoking and other environmental factors. It is more related to the incredibly rapid growth in the incidence adenocarcinoma—now the most rapidly increasing cancer in North America. As Dr Law points out, this is probably related to the increasing incidence of both morbid obesity and gastroesophageal reflux (GER). An additional factor in either the development or, more likely, the progression to cancer may be the widespread use of proton pump inhibitors (PPIs) as a symptomatic treatment of GER. Avissar et al have shown that, at the biologic level, genetic damage that is related to dysplasia progression is facilitated by the pH environment created by usual doses of PPIs.1 Certainly the fact that many patients with Barrett's esophagus have no or minimal GER symptoms complicates the possibility of screening to turn the tide of this cancer. Dr Law presents the arguments against screening very well—basically, too rare a cancer in too large an “at-risk” population. There remains a movement, however, that argues strongly for screening of high-risk individuals.2 Their argument includes the ease of screening, the high percentage of Barrett's esophagus in the gastroesophageal reflux disease (GERD) population (8–17%), and the 0.5–1% per annum dysplasia progression, which screening advocates describe as the equivalent risk profile of colon polyps. Colon polyps occur in 15% of colonoscopies, have a cancer progression risk of 0.5–1% per year, and yet claim a high priority for endoscopic screening. Finally, the argument that Barrett's screening is irrelevant because nothing would be done for anything but high-grade dysplasia (HGD) Barrett's esophagus is falling by the way as technologies like radiofrequency ablation (RFA) or cryotherapy show good efficacy at eradicating Barrett's esophagus3,4 and laparoscopic antireflux surgery induces regression in 30–40% of cases.5 Therefore, we may still see a future where routine screening for Barrett's esophagus makes sense, particularly as cancer rates continue to increase and better risk factor stratification is developed.6

All three chapters cover the never-ending controversy over the transhiatal/transthoracic approaches. Save the obvious holdout,7 there seems to be a gradual move to a more aggressive node-removing approach with a very gradual shift in outcomes data to support better cancer outcomes with en ...

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