Collard Jean-Marie
Upper G-I Surgery Unit, Louvain Medical School, Brussels, Belgium.
Chest Surg Clin N Am. 2002 Feb;12(1):77-92. doi: 10.1016/s1052-3359(03)00067-x.
The main principles for optimal management of HGD arising in Barrett's esophagus are that unequivocal diagnosis of HGD is a prerequisite for making the decision of any kind of treatment. HGD must be resected because of the presence of neoplastic cells in the lamina propria in 40% of patients. No reliable endoscopic or endosonographic feature exists that allows accurate prediction of the existence of neoplastic cells within the lamina propria of a patient having HGD in endoscopic biopsy material. Prompt decision to remove an HGD lesion as soon as unequivocal histologic diagnosis has been settled prevents the development of extraesophageal neoplastic spread. Esophagectomy is preferable to endoscopic mucosal excision because approximately 20% of patients who have HGD in preoperative biopsy material carry neoplastic cells beyond the muscularis mucosae. Esophagectomy can be limited to the removal of the esophageal tube without extended lymphadenectomy because 96% of patients who have HGD in endoscopic biopsy samples have a neoplastic process confined to the esophageal wall. Esophageal resection must encompass all the Barrett's area because of the risk for the further development of a second cancer in the metaplastic remnant. Vagus-sparing esophagectomy with colon interposition or elevation of the antrally innervated stomach up to the neck is preferable to conventional esophagectomy with gastric pull up because the former procedure maintains gastric function intact, whereas the latter exposes patients to the risk for the long-term development of reflux esophagitis and even of metaplastic transformation of the proximal esophageal remnant. Subtle details in the understanding of a given patient's clinical course may be critical for making the decision of the most relevant mode of therapy; therefore, patients who have HGD should be treated in dedicated centers, the experience of which offers the best chances of uneventful recovery if the surgical option is retained.
巴雷特食管中高级别异型增生（HGD）的最佳管理主要原则是，明确诊断HGD是决定任何治疗方式的前提。由于40%的患者固有层存在肿瘤细胞，HGD必须切除。在内镜活检材料中，不存在可靠的内镜或超声内镜特征能够准确预测HGD患者固有层内肿瘤细胞的存在。一旦明确组织学诊断，迅速决定切除HGD病变可防止食管外肿瘤扩散。食管切除术优于内镜黏膜切除术，因为术前活检材料中有HGD的患者中约20%的肿瘤细胞超出黏膜肌层。食管切除术可局限于切除食管管段，无需扩大淋巴结清扫，因为内镜活检样本中有HGD的患者96%的肿瘤病变局限于食管壁。由于化生残留有进一步发生第二种癌症的风险，食管切除必须包括所有巴雷特区域。保留迷走神经的食管切除术加结肠间置或将胃窦部神经支配的胃提升至颈部优于传统的胃上提食管切除术，因为前者可保持胃功能完整，而后者使患者面临长期发生反流性食管炎甚至近端食管残留化生转化的风险。了解特定患者临床病程的细微细节对于决定最相关的治疗方式可能至关重要；因此，HGD患者应在专门的中心接受治疗，如果选择手术，这些中心的经验能提供最佳的顺利康复机会。
