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Ann Arbor - The rapidly climbing obesity rates in the United States have created a higher risk
of esophageal cancer linked to reflux disease.
And this has some surgeons wondering if a currently popular procedure to remove the esophagus is as safe in obese
According to a new study at the University of Michigan Health System, obese
patients who underwent a procedure called transhiatal esophagectomy primarily for esophageal cancer had outcomes
similar to their lean counterparts.
"The type of patient who currently develops esophageal cancer has changed dramatically in the last 20 years.
Esophageal cancer used to be primarily squamous cell carcinoma found in people who drank alcohol and smoked
excessively. In association with the horrendous epidemic of obesity in this country, we have seen a 350 percent
increase of adenocarcinoma over the last 30 years. This is related to more gastroesophageal relux and Barrett's
esophagus in these patients," says
Mark Orringer, M.D., John Alexander Distinguished Professor of Surgery at the
U-M Medical School.
Orringer and lead study author Christopher Scipione, a U-M medical student, will present the study results
Tuesday, Jan. 30, at the Society of Thoracic Surgeons 43rd annual meeting in San Diego.
Adenocarcinoma of the esophagus is often the result of chronic reflux disease. When acid continuously backs up
into the esophagus, it wears down the natural lining. This can cause a condition called Barrett's esophagus in which
the body replaces the normal esophageal lining with one similar to that found in the intestines. People who develop
Barrett's are at a higher risk of developing adenocarcinoma.
Transhiatal esophagectomy, or THE, is an operation in which most of the esophagus is removed without the need to
open the chest, and swallowing is restored by pulling the stomach to the neck and connecting it there to the
remaining esophagus. THE is used to treat esophageal cancer and Barrett's esophagus with severe precancerous changes.
It was originally developed at the University of Michigan as a surgical alternative to removing the esophagus by
going through the chest, a much more difficult operation for the patient.
The researchers sought to determine if THE is a safe procedure for the growing number of obese patients requiring
esophageal surgery. They pulled the records of 133 profoundly obese patients who had this surgery at U-M between 1977
and 2006. Profound obesity was defined as a body mass index of 35 or more. Those 133 patients were matched to a
randomly selected control group of non-obese patients undergoing the same procedure. Both groups were matched for
factors including gender, age, year of operation and pre-existing medical conditions.
After comparing measures such as hospital length of stay, infection and mortality, the researchers found both
groups had comparable outcomes. This suggests the THE procedure is safe to perform in obese patients. The study
authors stress, however, that the results may be influenced by the high volume of patients U-M surgeons see for
this procedure. U-M surgeons perform 120 to 150 transhiatal esophagectomies each year and have completed more than
2,000 of these procedures in total. Because the procedure in obese patients is more demanding on surgeons, the
results may not be the same in hospitals that see relatively few patients in need of an esophagectomy.
"Profoundly obese patients undergoing a THE at a high-volume center can have surprisingly and acceptably low
morbidity and mortality rates, similar to those of non-obese individuals matched for co-morbidities," says Orringer,
head of the U-M Section of Thoracic Surgery and co-director
of the Thoracic Oncology Program at the U-M Comprehensive
Currently about 85 percent of esophageal cancers removed in this country are adenocarcinomas, most related to
obesity and reflux disease, and 15 percent are squamous cell carcinomas, typically due to smoking or alcohol
consumption. Two decades ago, those numbers were reversed.
"Reflux is an extraordinarily common problem now, and it's because we're a fat society. If heartburn is
persistent or chronic, patients should have a thorough exam and endoscopy to see if they have developed Barrett's
esophagus, which carries an increased risk of cancer and signals the need for close surveillance with periodic
endoscopies and biopsies," Orringer says.
About 14,500 people will develop esophageal cancer this year. For more information on this disease, contact
Cancer AnswerLine™ at 800-865-1125 or visit the
esophageal cancer web page.
In addition to Orringer and Scipione, study authors were Alfred Chang, M.D., Allan Pickens, M.D., and Christine
Lau, M.D., all from the U-M Department of Surgery Section of Thoracic Surgery.
Reference: Society of Thoracic Surgeons 43rd annual meeting, Jan. 29-31, 2007, San Diego, Calif.
Written by Nicole Fawcett
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