Jack Selby had suffered from heartburn all of his life, especially around the holidays when he overindulged in some of his favorite food and drink.
“Special days anytime of the year, but particularly holidays, the turkeys and the gravies and all of the dishes with onions, great salads, punches and alcohol bothered me a great deal because of the stomach acid and of course you overeat and fall asleep,” says Selby, a 68-year-old retiree living in Lansing, Mich. “So that’s not a particularly good thing to have happen.”
He thought over-the-counter antacids had solved his problem. It turns out they were only masking a condition known as Barrett’s esophagus, a disorder that frequently leads to a form of esophageal cancer called adenocarcinoma..
The incidence of esophageal adenocarcinoma has increased by 350 percent over the last decade, making it the most rapidly increasing malignancy among white males.
“People who have ongoing gastro-esophageal reflux, which is backwash of acid from the stomach into the esophagus, for years and years, expose the lining of the esophagus to this bombardment of acid,” says Mark Orringer, M.D., professor of surgery in the Section of Thoracic Surgery at the University of Michigan Health System.
“The esophagus was never meant to hold up to acid, and with unrelenting acid reflux over the years, that lining gets burned, and can have significant implications.”
Selby required an esophagectomy, a removal of the esophagus for Barrett’s mucosa and early stage esophageal cancer.
He was treated by Orringer at the University of Michigan, a national leader in performing a type of esophagectomy--transhiatal esophagectomy, or THE-- which is less-invasive than the originally used method of esophagectomy that was performed through a chest incision.
Today the procedure is done in a minimally invasive procedure, with a high patient survival rate. This month, the U-M performed its 3,000th procedure.
How it works
“It has long been known that esophagectomy is an operation that has a tremendous physical impact on the patient,” says Orringer. “Many years ago the esophagectomy operation, the traditional operation done through the chest, carried upward of a 20 percent mortality rate; 1 out of 5 patients would die as we attempted to try to provide them comfortable swallowing and allow them to eat for the remaining time that they had left.
”With the advent and the refinement of the transhiatal esophagectomy, the death rate from the procedure, is under 1 percent at the U-M.”
Transhiatal esophagectomy was developed and refined at the U-M and involves removing the diseased esophagus and rebuilding it. The procedure is performed through an incision in the neck and the abdomen and eliminates the need to open the chest – an approach still used at some health centers.
Hospitals that perform six to 10 esophagectomies a year are considered high volume.
But the U-M Health System performs 120 to 140 of the operations a year and their teams have extensive experience in handling both the routine and unusual events which can surround the large operation that allows patients to eat and swallow normally afterwards.
“I had the total esophagectomy done about 15 months ago and I’m doing great now,” says Selby, who gained weight after retiring and weighed 260 before the esophagectomy. “I’ve lost about 70 pounds, which of course you get a whole new wardrobe and I have lots of energy and I feel very good.”
America’s reflux epidemic
According to Orringer, there is literally an epidemic of reflux in the United States today and the epidemic is directly related to obesity.
”Some widely available potent acid reducing drugs such as H2 blockers and proton pump inhibitors can absolutely turn off acid production by the stomach -- and virtually eliminate heartburn. Unfortunately, patients often feel that when the heartburn’s gone, the problem is gone,” Orringer explains.
Patients who have had their esophagus burned repeatedly by stomach acid for years and years have an increased incidence of developing cancer, and the Barrett’s lining is the first sign of serious complications.
Barrett’s is diagnosed by placing a lighted scope in the esophagus, called an esophagoscopy, and performing a biopsy of the lining of the esophagus which is an 11-inch long tube that runs from the throat to the stomach. The esophagus carries swallowed food to the stomach to be digested.
“Barrett’s is not predictable and has to be followed to see if it’s developing any of the signs of malignancy or a change to cancer, and that’s not related to whether you have heartburn or not,” he says.
If heartburn becomes worse than normal, or patients begin having difficulty swallowing, a condition called dysplasia, it can indicate that something more serious is going on in the esophagus than heart burn from overeating rich foods and holiday treats.
“A little bit of heartburn between Christmas and New Year’s isn’t going to kill us from cancer, but prolonged heartburn because we overeat, we eat late at night, we sit in front of the television and have a snack before we lay down at night with a full stomach, or are overweight, is an issue to be aware of,” says the thoracic surgeon.