Abstract and Introduction
Introduction
Gastro-oesophageal reflux disease (GERD) has become the most important oesophageal issue of the 21st century. It is defined by the Montreal International Consensus as a 'condition which develops when the reflux of stomach contents causes troublesome symptoms and or complications.' To surgeons, its importance lies not only in its prevalence but, more importantly, in its potential to lead to adenocarcinoma of the oesophagus. GERD affects between 18% and 28% of the US population, and approximately 8%–15% of these patients will go on to develop the premalignant condition of Barrett's oesophagus. The two most prevalent types of oesophageal carcinoma are squamous cell and adenocarcinoma. Squamous cell carcinoma used to be the most prevalent oesophageal cancer in the Western world, but it has been surpassed by oesophageal adenocarcinoma in the last 40 years. Oesophageal adenocarcinoma primarily affects white men with GERD, while squamous cell carcinoma is more commonly associated with tobacco and alcohol use.
Oesophageal adenocarcinoma is an extremely lethal form of cancer with a five-year survival rate of 15%–20% despite best available therapy. The five-year mortality rate in early stage disease has been reported to be as high as 63%. GERD is a prevalent disease affecting nearly one-quarter of Americans and Barrett's oesophagus is a known complication of GERD. For clarity, Barrett's oesophagus is defined as specialised intestinal metaplasia of the metaplastic columnar epithelium. Of those with Barrett's oesophagus, approximately 0.12%–0.38% per year will progress to oesophageal adenocarcinoma. We know that chronic GERD leads to Barrett's oesophagus, which is a precursor to oesophageal adenocarcinoma. Since we have effective treatment for Barrett's oesophagus, why then does the incidence of oesophageal cancer continue to rise in the USA?
Since the 1970s, there has been a nearly 400% increase in the incidence of oesophageal adenocarcinoma. Less than 5% of patients who develop oesophageal adenocarcinoma have a previous diagnosis of Barrett's oesophagus, and 38%–50% of patients with oesophageal adenocarcinoma present with metastases. Physicians and surgeons are not adequately identifying patients at risk for Barrett's. We are failing to refer these patients for early evaluation and intervention of this potentially preventable disease. Instead, patients are presenting late after they have already developed invasive adenocarcinoma. At this late stage, surgery, chemotherapy and radiotherapy are often only palliative.
Like obesity, GERD has become a public health problem which requires attention from all specialties. In general, the goal of oesophageal surgeons is to first control GERD by a combination of medical and surgical therapy in order to prevent the development of reflux oesophagitis and subsequently Barrett's oesophagus. If Barrett's oesophagus is already established at the time of patient presentation, the focus is then on monitoring the oesophagus for the early signs of dysplasia. If dysplasia is present, eradication of Barrett's oesophagus using radio-frequency ablation (RFA) or endoscopic mucosal resection is appropriate. If a patient is non-responsive to less invasive therapy, or progresses to invasive oesophageal adenocarcinoma, oesophagectomy with oesophageal replacement is frequently indicated in the absence of distant metastases. If metastasis has occurred, then chemoradiotherapy or hospice care may be appropriate. The focus of this review is to provide an overview of the various surgical treatments for GERD, Barrett's oesophagus and oesophageal adenocarcinoma in order to help demystify the surgical treatment of this disease for pathologists. Major advances in diagnosis and prevention of this disease will likely come from histopathologists who can characterise the details of disease progression. A common language should then be established between surgeons and pathologists to integrate clinical and pathological information to better manage patients in the future.