Stein Hubert J, Feith Marcus, von Rahden Burkhard H A, Siewert J Rüdiger
Chirurgische Klinik und Poliklinik der Technischen Universität München, Klinikum Rechts der Isar, Ismaningerstrasse 22, D-81675, München, Germany.
World J Surg. 2003 Sep;27(9):1040-6. doi: 10.1007/s00268-003-7059-8. Epub 2003 Aug 18.
Because of effective surveillance programs in patients with known Barrett's esophagus, adenocarcinoma of the distal esophagus is increasingly diagnosed at early stages. With the introduction of limited surgical and endoscopic treatment modalities, the need for radical esophagectomy and extensive lymphadenectomy in such patients has been questioned. When selecting the approach to early Barrett's cancer, the precancerous nature of the underlying Barrett's esophagus, the frequent multicentricity of neoplastic alterations within the Barrett mucosa, the inaccuracy of current staging modalities, and the presence of lymph node metastases should be taken into account. Invasiveness and morbidity of the procedures, as well as quality of life aspects, should also be considered. From an oncologic point of view the minimum extent of a resection for early Barrett's cancer should include a full-thickness removal of the entire segment of the distal esophagus covered by intestinal metaplasia together with a regional lymphadenectomy. In appropriately selected patients this can be achieved by a limited surgical procedure involving transhiatal resection of the distal esophagus, but not by endoscopic mucosal ablation or endoscopic mucosa resection. Our experience with 49 limited surgical resections with regional lymphadenectomy indicates that this procedure is oncologically adequate and safe. Reconstruction with an interposed jejunal loop prevents postoperative gastroesophageal reflux and is associated with good quality of life. In contrast, endoscopic interventions are plagued by a high tumor recurrence rate, probably from persistence of Barrett's mucosa and gastroesophageal reflux.
由于对已知巴雷特食管患者实施了有效的监测计划，远端食管癌在早期被诊断出的情况越来越多。随着有限的手术和内镜治疗方式的引入，这类患者对根治性食管切除术和广泛淋巴结清扫术的需求受到了质疑。在选择早期巴雷特癌的治疗方法时，应考虑潜在巴雷特食管的癌前性质、巴雷特黏膜内肿瘤性改变常见的多中心性、当前分期方式的不准确性以及淋巴结转移的存在。还应考虑手术的侵袭性和发病率以及生活质量方面。从肿瘤学角度来看，早期巴雷特癌切除的最小范围应包括对肠化生覆盖的远端食管整个节段进行全层切除以及区域淋巴结清扫。在适当选择的患者中，这可以通过涉及经裂孔切除远端食管的有限手术来实现，但不能通过内镜黏膜消融或内镜黏膜切除术来实现。我们对49例进行区域淋巴结清扫的有限手术切除的经验表明，该手术在肿瘤学上是足够的且安全的。用空肠袢进行重建可防止术后胃食管反流，并与良好的生活质量相关。相比之下，内镜干预存在肿瘤复发率高的问题，这可能是由于巴雷特黏膜和胃食管反流持续存在所致。
