Esophageal resection for high-grade dysplasia and intramucosal carcinoma: When and how?

Table 1 High-risk characteristics associated with submucosal invasion, lymph node metastasis, or unsuccessful endoscopic therapy

Endoscopic characteristics

Long-segment Barrett’s esophagus

Visible lesions with high risk endoscopic characteristics

Polypoid mass

Excavated lesions or ulcers

Evidence of lymph node involvement by EUS + FNA

Pathological characteristics

Multifocal HGD

Evidence of submucosal invasion

Deeper two thirds of the submucosa carries high risk of lymph node metastasis

Moderately or poorly differentiated tumor

Evidence of lymphatic channel invasion

Evidence of vascular invasion

Evidence of neural invasion

Treatment characteristics

Failure of ablation of remainder for Barrett’s epithelium

Piecemeal endoscopic resection (as opposed to en bloc resection)

Longer time to achieve eradication

EUS: Endoscopic ultrasound; FNA: Fine needle aspiration; HGD: High-grade dysplasia.

Table 2 Relative risk of submucosal invasion associated with endoscopic appearance of lesions

Endoscopic appearance	Paris classification	Relative risk of submucosal invasion
Polypoid	0-Ip	Higher
Sessile	0-Is	Higher
Slightly raised	0-Ia	Low
Flat	0-Ib	Low
Slightly depressed	0-Ic	Higher
Excavated	0-III	Very high

Table 3 Selecting an appropriate surgical approach

Patient characteristics

Prior surgery (thoracic, abdominal, esophageal)

Obesity

Age

Pulmonary function

Other comorbid factors

Surgical options

Standard open resection

Transhiatal esophagectomy (2 or 3 holes)

Minimally invasive esophagectomy

Vagus sparing esophagectomy

Mucosal stripping esophagectomy?

Extent of operation

Extent of esophageal resection

Limited resection of Barrett’s segment

Near-total esophagectomy

Extent of soft tissue resection

Minimal

Standard

Extended

Extent of nodal dissection

Minimal

Standard

Extended 3-field

Surgical results

Accuracy of staging

Number of lymph nodes

Effects on long-term survival

Effects on perioperative outcomes