Marco Patti, MD, gives his presentation - Update on Surgical Approaches: Esophagus.
MARCO PATTI, MD: I will touch upon three different disease processes. Gastroesophageal reflux disease, in terms of diagnosis. And then achalasia and Barrett's esophagus, expanding on what Dr. O'Connor was saying. I have nothing to disclose. But a common theme of all this work is really, at University of Chicago, we're working as a real team. The Center was created six years ago, and it really puts together gastroenterologists, surgeons, pulmonologists, cardiologists, radiologists. And I think that the good results that we are achieving today are really due to this collaboration. So let me start with gastroesophageal reflux disease. A few years ago, two companies came up with a different system of evaluating reflux, is the so-called impedance-pH. Now the concept is brilliant, because you can measure reflux independent from the pH. And then, if you at the same time have sensors, you can determine if the reflux is acidic, weakly acidic, or alkaline. And this was important to understand a little bit more of the pathophysiology of the disease. As you can see on this slide, when you give proton-pump inhibitors, you are not stopping reflux. The same number of reflux episodes will occur, because it's a mechanical problem. It's a functional problem, due to the lower esophageal sphincter. All you're doing, either in the preprandial or postprandial time, is just changing the pH of what is going from the stomach into the esophagus. So from a therapeutic point of view, this has important implications. Specifically, if you have a patient that has respiratory symptoms and you feel that they are due to reflux, if you have a negative response to proton-pump inhibitors, it might not mean that the patient doesn't have reflux causing the cough. It might just mean that they're still refluxing material that is non-acidic. Now, unfortunately, pH impedance has major problems. The first one is that the two companies didn't really spend too much time developing the software. So they consider an abnormal study if you're more than 73 episodes of reflux. But they don't tell you if the episodes are one second long, five minutes, or ten minutes. So that makes a huge difference. In addition, there is a major problem in the interpretation of the tracings. So this was a very nice study that was presented to the Society for Surgery of the Alimentary Track during the Digestive Disease Week. And this is the group from Cornell University. What they found was there were major differences between the software analysis and the analysis done by expect gastroenterologists. Number two, there was also major differences in the analysis done by the different gastroenterologists that looked at the tracings. And if you want to really examine a tracing, it will take anywhere between 2 and 1/2 and five hours, even if you have done it before. So in my mind, impedance-pH at the present time has very little clinical applicability. So if you are trying to decide if a patient is respited to symptoms that are due to reflux, I think that the way to do it is use the old-fashioned pH monitoring. We're using a catheter that has two sensors, as you can see in the right side of the slide. One is placed five centimeters above the LES. And the other is really the thoracic inlet or pharynx. Many started in transplant patients-- and I say transplant patients because you can then do bronchoscopy and lavage-- have shown that if you have reflux at the level of the pharynx, you're having an episode of microrespiration. And those were determined by looking for pepsin in the bronchoalveolar lavage. And there is now recognition that reflux plays a major role in respiratory symptoms. And finally, the NIH has agreed to fund a study-- will be prospective, will be randomized, will be multi-center. And we're trying to determine if by stopping reflux with a fundoplication we can alter the natural [INAUDIBLE]. And especially, avoid for patient the need for a lung transplant. We are enrolling the first patients in July. Now, let me switch to another disease, achalasia. Today, we have the three common modalities available. Dilatation, POEM, the peroral endoscope, and Heller myotomy. But the question is, if you have a patient with achalasia in your office, what should be the primary form of treatment? Well, let me show the data that's available. A couple of years ago, during the Digestive Disease Week, this very important study was presented. It eventually was published in The New England Journal of Medicine. It was a European, multi-center trial comparing pneumatic dilatation to a Heller myotomy with fundoplication. At a short-term follow up, two years, the results were very similar. About 90% of patients we're doing very well, as shown by a score of less than 0.3. But if you analyze carefully this study, you will find that there are some problems. Number one, they compare treatment by the best gastroenterologists in Europe with surgeons who did not have as much experience . So you have a perforation rate with pneumatic dilation of only 4%. But the perforation rate during the myotomy in patients who had never been treated before-- so you're looking at a virgin esophagus-- was 12%. That's huge. In addition, and Dr. Cavitt can confirm it, because of the excellent results of the Heller myotomy, fewer and fewer fellows in gastroenterology develop today enough experience with pneumatic dilatation for achalasia during their training. In addition, it's true that pneumatic dilatation is an outpatient procedure, but we have to repeat it over time. In a Heller myotomy, you stay one or two days in the hospital, but then that's it. The study confirmed again that younger patients do better with a Heller's myotomy. And then, there are two other points that are important. We do not have the follow-up in this study. Strangely enough, we don't have any information. But we know from prior studies that if you look at the ten-year results of the pneumatic dilatation, only 50% of patients are doing well, even after multiple sessions. In contrast, it's about 90% with surgery. Finally, in the editorial to The New England Journal, Dr. Spechler suggests that you should always try pneumatic dilatation first. And if it fails, you should do a myotomy. It doesn't make sense because multiple studies have shown that you do a Heller myotomy in patients that have been treated before, either with pneumatic dilatation, or botulinum toxin, the results are not as good. Then there is POEM, this new treatment modality. The first study was presented in Norway from Yokohama in Japan in 2010. As you can see in this diagram on the left side of the slide, you create a submucosal tunnel, about 15 centimeters above the gastroesophageal junction. Then you introduce a knife and cut the circular fibers. You go onto the stomach for about two or three centimeters. This study was followed by the first report in the United States. This was presented in 2012. It's the group of Lee Swanstrom in Portland. 18 patients were treated. Hospital stay, one day. And as you can see, at one-year follow up, the results were excellent in every patient. But there are some problems. As you can see, when the endoscopy was done during follow up, 28% of patients had esophagitis. And this makes sense because you are cutting the lower esophageal sphincter, but you're not doing an anti-reflux operation. And the 24-hour pitch monitoring showed that's about 50% of patients had pathologic reflux. Now it is not a trivial problem because remember, that by definition, in achalasia, there is not peristalsis. So we have more and more cases of patients that have developed Barrett's esophagus after treatment and even adenocarcinoma. Finally, I know that as endoscopies, that most of you are very familiar with these. When you're doing pneumatic dilatation, the best predictor of long-term success is if you're able to bring the pressure of the lower esophageal sphincter around 10 millimeters of mercury. A common theme of all these POEM procedures is that the pressure stays anywhere between 15 and 20 millimeters of mercury. So there is a predictor of long-term failure. And then, finally, there was this study, multi-center, for centers in Europe and McGill University in Canada. They treated 70 patients, 12 months that follow-up in 51. But as you can see, 82% percent were doing well, which means that 18% of the patients they treated were having recurrent dysphagia. Let me tell you that I would be out the business if I had these results in Chicago, which is an incredibly competitive place. In addition, you can see that there were major complications, perforation in the mediastinum, 69%. In the peritoneal cavity, 57%. These were very skilled endoscopies and surgeons. So no patients eventually asepsis and died. At follow-up, they did endoscopy, and 42% percent of patients had esophagitis. So if you put all this data together, in the big picture, there is no question that this technique is giving excellent short-term results. But it's new, so it should be done in centers where gastroenterologists, surgeons, radiologists, work together. I am not able to do it myself, because I think it requires superior endoscopic skills. And I think that it wull be part of the armamentarium, but we have to figure out which patients to select. At the end of the day, why are we doing POEM? To avoid five small incisions? The length of stay is longer than a Heller's myotomy. As I mentioned before, the pressure stays high, so there is a risk of recurrence. If you perforate the esophagus at the mediastinum, or in the peritoneum, sooner or later, somebody will die of asepsis, whereas the first case of a young woman that died in Maryland. We don't have long-term results. So I think that the prospective around the mistrial is important. And that's why you have to compare to a technique that has been around for 100 years. Maybe during the last 24, we've done it laparoscopically. But it gives excellent results. With a laparoscopic myotomy, you have better results at 10-year in about 90% percent of patients, as shown by the studies, either in Australia, Canada, Europe, or the United States. The results are excellent. And in addition, when you do a Heller's myotomy, and you do a partial fundoplication, you are treating dysphagia, but also, you're preventing reflux. And that's one of the problems with POEM. This is the operation we do. We use five small incisions and then we do a myotomy. We try to extend it on the stomach for about 2 centimeters. And then we do a partial anterior fundoplication to prevent reflux. Overall, this is the treatment algorithm we use at University of Chicago. We start with a laparoscopic Heller myotomy. In case of failure, patients do incredibly well with pneumatic dilatation. So we tell patients, listen. If you feel that you're having again a little bit of dysphagia, don't wait for the dysphagia to get worse. And I send the patient to Dr. O'Connor, Dr. Carvey,, to do a dilatation, and those patients actually do very well. It is because there is some scarring at the end of the myotomy. In case of failure, you have the classic options of trying again an operation. Maybe POEM in the posterior wall of the esophagus will play a role. And then, if this patient fails, we go to a esophagectomy. So overall, I think that the best results, again, is the idea of the team, are obtained in centers where you have cardiologists, gastroenterologists, and surgeons, so they choose together the best modality of treatment. Now, let me expand a little bit on what Dr. O'Connor was saying. And again, this is the idea of working together and do the best for our patients. There is no questions that these endoscopic modality have completely revolutionized the treatment of high grade dysplagia and intramucosal cancer. And there is no questions that this has really decreased the number of patients that need an esophagectomy. But let me warn about a couple of things. First of all, again, you need to have a multi-disciplinary approach. You need to select the patients very carefully. You need to do an endoscopic ultrasound. You need to have the skill, endoscopic expertise. But the key points I want to stress are the importance of the follow up, because some of these patients will have a recurrence. So this is a study that comes from Hamburg, Germany. They had 90 patients that they did an endoscopic treatment with a combination, as Dr. O'Connor was mentioning, of EMR radiofrequency ablation. In 90% of patients, that had complete eradication of the parastitial. But as you can see, there were five patients that had recurrence at a median of 44 months. But a patient had the recurrence 85 months after complete eradication of the Barrett's esophagus. So the point is, I think these are fabulous modalities. But you want to make sure that you explain to patients that they are enrolled in a follow-up protocol for the rest of their life. Why do they need this strict follow up? To avoid this other problem. These are patients that were treated in Seattle, Portland, and the University of Southern California. So where 15 patients that initially had endoscopic therapy, but they were not part of a strict follow up. So some patients came back with cancer. The problem is that submucosal invasion was found in the specimen in 27% percent of them. And 20% had positive nodes. And when you have positive nodes in esophageal cancer, your survival is not great. So let's just remember that these patients had a curable disease at time of presentation. So again, make sure that the patients are enrolled in a strict protocol and a follow up. So I think esophagectomy, in some patients, still has a role. One, when the endoscopic expertise is not available. If patients cannot have a rigid follow up. I feel that when you have multifocal dysplasia in a lung segment, this is the best way to treat the patients. When you don't achieve complete eradication. So it's not only the ammar. You have to use radiofrequency ablation to make sure that there is no more columnary repitilian that is left. And then, I think a esophagectomy has a role when you're dealing with a patient, an EMR shows that there's more than a T1A. For a T1B, you really have to do a esophagectomy because it's curative, because in a high-volume center, we can keep the mortality to less than 1%. And today, we are developing new techniques. So in most patients we can do a completely minimally invasive esophagectomy. I thank again for all your attention. [APPLAUSE]
