EDITORIAL COMMENTARY
Editorial Commentary: Endoscopically Closing Doors Anthony W. Kim, MD (Associate Professor) The use of radiofrequency ablation with or without endoscopic mucosal resection for the treatment of Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinomas (IMC) has emerged as a therapeutic alternative to esophageal resections among medically fit patients, as evidenced by national guidelines.1 The findings reported by Lada et al2 provide additional evidence supporting this alternative to surgery. Aside from lending support, the authors’ data are valuable because they document the added dimension of longitudinal follow-up. With this longitudinal follow-up, the natural history of patients undergoing endoscopic therapy with progressive BE is better understood. To illustrate this point, although the reported complete responses for IMCs and HGDs treated endoscopically are quite impressive, the fact that recurrences or progression of disease was treated using repeat endoscopic therapies rather than resorting to operative therapy is quite remarkable. This fact alone endorses the promise of endoscopic therapies for early-stage esophageal malignancies. Consequently, the fact that their multivariate analysis did not further identify factors found on univariate analysis to be prognostic for the failure to eradicate dysplasia or BE or for the development of recurrence is largely irrelevant, given that repeat endoscopic therapies appear to be adequate in addressing these issues. The authors’ thought-provoking data challenges the classic thinking that surgical therapy is the “gold standard” for all forms of resectable esophageal malignancies, and for this perspective alone, they should be congratulated. They reinforce their contention that the need for esophagectomies can be eliminated by virtue of their own institutional experience, where esophagectomies for IMCs and HGDs has decreased markedly. Interestingly, the elimination of esophagectomy for IMC and HGD appears to have been replaced by the relatively arduous surveillance process and re-treating patients endoscopically. In their cohort of 57 patients, when including surveillance endoscopies among the diagnostic and therapeutic endoscopic Section of Thoracic Surgery, Yale School of Medicine, 330 Cedar St, BB 205, New Haven, CT 06520
1043-0679/$-see front matter ª 2015 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2015.02.003
interventions, 753 procedures were performed with a median of 13 procedures per patient (range: 3-33 procedures). When extrapolated to an individual surgeon’s practice, these numbers raise the issue of costeffectiveness in treating a handful of these patients. Furthermore, to duplicate the results of the authors, it would seem that a practice would have to be organized to include other like-minded surgeons with a shared programmatic vision who can deliver the level of care described by the authors. Otherwise, given the constraints and demands on an individual surgeon, there is the distinct possibility that the treatment, surveillance, and re-treatment of these patients could spill over a territorial line shared with our gastroenterology colleagues. Given what has been observed among some surgical specialties that have lagged in maintaining footholds in shared advances with other nonsurgical disciplines, it is important that thoracic surgeons maintain a meaningful grasp on these endoscopic techniques and their attendant technologies, especially if we are to consider it as an alternative to esophagectomy. Moreover, through being invested, it is important that we maintain the ability to intervene with surgical resection when the circumstances dictate that operative therapy is superior or preferred. Ultimately, as the authors acknowledge in their limitations, a surgically resected specimen remains the standard by which the claim of a true complete response can be definitively asserted. Obviously, the driver behind the decision to pursue endoscopic therapies for BE-related HGDs and IMCs are based on what is best for the individual patient. Even among institutions with the highest volumes and the most experienced surgeons, minimally invasive esophagectomies are still associated with higher incidences of morbidities than what is described in this report; therefore, it is difficult to argue against the use of a lesser-invasive approach that achieves excellent results. Nevertheless, as the authors have done with their own experience, each thoracic surgeon must carefully decide upon who would benefit from this form of endoscopic therapy vs surgical resection. Ultimately, as the history of thoracic surgery has revealed in the past and as it will continue to demonstrate in the future, the evolution 285
EDITORIAL COMMENTARY: ENDOSCOPICALLY CLOSING DOORS of nonoperative therapies in the treatment of thoracic diseases is important for the growth of our discipline, in general. We should view these types of advances
as avenues for other possibilities rather than doors that close on existing practices. The work by Lada et al. is another step in that direction.
1. National Comprehensive Cancer Network Available at: www.NCCN.org. Accessed October (NCCN) Clinical Practice Guidelines in Oncol14, 2014. ogy (NCCN Guideliness). Esophageal and eso- 2. Lada MJ, Watson TJ, Shakoor A, Nieman DR, phagogastric junction cancers. Version 1.2014. Han M, Tschoner A, Peyre CG, Jones CE, Peters JH.
286
Eliminating a need for esophagectomy: endoscopic treatment of Barrett’s esophagus with early esophageal neoplasia. J Thorac Cardiovasc Surg.
Seminars in Thoracic and Cardiovascular Surgery Volume 26, Number 4
Editorial Commentary: Endoscopically Closing Doors Anthony W. Kim, MD (Associate Professor) The use of radiofrequency ablation with or without endoscopic mucosal resection for the treatment of Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinomas (IMC) has emerged as a therapeutic alternative to esophageal resections among medically fit patients, as evidenced by national guidelines.1 The findings reported by Lada et al2 provide additional evidence supporting this alternative to surgery. Aside from lending support, the authors’ data are valuable because they document the added dimension of longitudinal follow-up. With this longitudinal follow-up, the natural history of patients undergoing endoscopic therapy with progressive BE is better understood. To illustrate this point, although the reported complete responses for IMCs and HGDs treated endoscopically are quite impressive, the fact that recurrences or progression of disease was treated using repeat endoscopic therapies rather than resorting to operative therapy is quite remarkable. This fact alone endorses the promise of endoscopic therapies for early-stage esophageal malignancies. Consequently, the fact that their multivariate analysis did not further identify factors found on univariate analysis to be prognostic for the failure to eradicate dysplasia or BE or for the development of recurrence is largely irrelevant, given that repeat endoscopic therapies appear to be adequate in addressing these issues. The authors’ thought-provoking data challenges the classic thinking that surgical therapy is the “gold standard” for all forms of resectable esophageal malignancies, and for this perspective alone, they should be congratulated. They reinforce their contention that the need for esophagectomies can be eliminated by virtue of their own institutional experience, where esophagectomies for IMCs and HGDs has decreased markedly. Interestingly, the elimination of esophagectomy for IMC and HGD appears to have been replaced by the relatively arduous surveillance process and re-treating patients endoscopically. In their cohort of 57 patients, when including surveillance endoscopies among the diagnostic and therapeutic endoscopic Section of Thoracic Surgery, Yale School of Medicine, 330 Cedar St, BB 205, New Haven, CT 06520
1043-0679/$-see front matter ª 2015 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2015.02.003
interventions, 753 procedures were performed with a median of 13 procedures per patient (range: 3-33 procedures). When extrapolated to an individual surgeon’s practice, these numbers raise the issue of costeffectiveness in treating a handful of these patients. Furthermore, to duplicate the results of the authors, it would seem that a practice would have to be organized to include other like-minded surgeons with a shared programmatic vision who can deliver the level of care described by the authors. Otherwise, given the constraints and demands on an individual surgeon, there is the distinct possibility that the treatment, surveillance, and re-treatment of these patients could spill over a territorial line shared with our gastroenterology colleagues. Given what has been observed among some surgical specialties that have lagged in maintaining footholds in shared advances with other nonsurgical disciplines, it is important that thoracic surgeons maintain a meaningful grasp on these endoscopic techniques and their attendant technologies, especially if we are to consider it as an alternative to esophagectomy. Moreover, through being invested, it is important that we maintain the ability to intervene with surgical resection when the circumstances dictate that operative therapy is superior or preferred. Ultimately, as the authors acknowledge in their limitations, a surgically resected specimen remains the standard by which the claim of a true complete response can be definitively asserted. Obviously, the driver behind the decision to pursue endoscopic therapies for BE-related HGDs and IMCs are based on what is best for the individual patient. Even among institutions with the highest volumes and the most experienced surgeons, minimally invasive esophagectomies are still associated with higher incidences of morbidities than what is described in this report; therefore, it is difficult to argue against the use of a lesser-invasive approach that achieves excellent results. Nevertheless, as the authors have done with their own experience, each thoracic surgeon must carefully decide upon who would benefit from this form of endoscopic therapy vs surgical resection. Ultimately, as the history of thoracic surgery has revealed in the past and as it will continue to demonstrate in the future, the evolution 285
EDITORIAL COMMENTARY: ENDOSCOPICALLY CLOSING DOORS of nonoperative therapies in the treatment of thoracic diseases is important for the growth of our discipline, in general. We should view these types of advances
as avenues for other possibilities rather than doors that close on existing practices. The work by Lada et al. is another step in that direction.
1. National Comprehensive Cancer Network Available at: www.NCCN.org. Accessed October (NCCN) Clinical Practice Guidelines in Oncol14, 2014. ogy (NCCN Guideliness). Esophageal and eso- 2. Lada MJ, Watson TJ, Shakoor A, Nieman DR, phagogastric junction cancers. Version 1.2014. Han M, Tschoner A, Peyre CG, Jones CE, Peters JH.
286
Eliminating a need for esophagectomy: endoscopic treatment of Barrett’s esophagus with early esophageal neoplasia. J Thorac Cardiovasc Surg.
Seminars in Thoracic and Cardiovascular Surgery Volume 26, Number 4
