Treatment of Barrett's esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy

Background: Endoscopic therapies for early neoplasia in Barrett's esophagus may be a viable alternative to esophagectomy. Objective: Our purpose was to compare endoscopic therapy and esophagectomy. Design: Retrospective review from a single institution. Setting: A medium-sized tertiary referral center. Patients and interventions: All patients with Barrett's esophagus and dysplasia or intramucosal carcinoma treated by photodynamic therapy (PDT), EMR, or argon plasma coagulation (APC) or esophagectomy with curative intent from May 1998 until November 2005. Main Outcome Measurements: Survival, progression to cancer, eradication of dysplasia and Barrett's esophagus, major and minor complications, and costs were compared. Results: Sixty-two patients who underwent endoscopic therapy (2 APC alone, 18 EMR + APC, 20 PDT + APC, and 22 EMR + PDT + APC) and 32 patients who underwent esophagectomy met the inclusion criteria. The 30-day mortality rate included 1 patient in the endotherapy group (2%) and none in the surgical group (P = .49). No deaths from esophageal cancer occurred in either group. Cancer developed in 6% of endotherapy patients and in none in the surgical cohort (P <.05). Major and minor complications occurred in 8% and 31% of endotherapy patients, respectively, and 13% and 63% of surgery patients (P = .50, P < .001). Median cost to date was $40,079 for endotherapy and $66,060 for esophagectomy (P <.001). Limitations: Retrospective study, relatively short follow-up, small numbers. Conclusions: Both endotherapy and esophagectomy can effectively treat high-grade dysplasia and intramucosal carcinoma associated with Barrett's esophagus. Endotherapy is associated with a higher risk of tumor progression, although this is uncommon. Esophagectomy incurs higher initial costs and results in more frequent minor complications but is usually curative.