Internal Medicine, Loma Linda Veterans Health Care System, Loma Linda, CA 92357, USA.
Dig Dis Sci. 2010 Jun;55(6):1615-21. doi: 10.1007/s10620-009-0917-y. Epub 2009 Aug 11.
Determine the rates of follow-up, incident rate of cancer during surveillance, and changes in pathologic grade of patients with Barrett's esophagus during surveillance in a gastroenterology practice without a formal surveillance program.
Barrett's esophagus is a pre-malignant condition. Surveillance endoscopy (SE) is recommended in order to detect and treat high-grade dysplasia and esophageal adenocarcinoma early and prevent deaths. SE has not been shown to have mortality benefit and several studies have questioned its cost-effectiveness. Most gastroenterology practices do not have a surveillance program for Barrett's esophagus. The few that exist are only in very specialized and funded programs. Little information exists on outcomes in patients with Barrett's esophagus outside of these well-structured surveillance programs.
A retrospective analysis of a cohort of patients with Barrett's esophagus diagnosed and surveyed between 1995 and 2005 at a Veterans Affairs medical center. Data were collected on age, body mass index, and race. Patients who missed their SE by 6 months or more and those that missed their SE by twice the recommended intervals or more were identified and analyzed for changes in pathologic grades.
A total of 472 patients were diagnosed with Barrett's esophagus or had SE between 1995 and 2005. Three hundred and five patients only had one endoscopy and biopsy. They did not have follow-up surveillance endoscopies and biopsies. Two patients were excluded from the final analysis: one had an esophagectomy after an index diagnosis of high-grade dysplasia, and one had a diagnosis of esophageal adenocarcinoma 2 days after an initial impression of Barrett's esophagus. There were 165 patients with Barrett's metaplasia or dysplasia who had SE more than once and were included in the final analysis. Overall, 53.3% had no change in pathologic grade, 35.2% regressed to a lower pathologic grade, and 11.5% progressed to a higher grade. None (0/165, 0%) progressed to esophageal adenocarcinoma; 3.6% (6/165) progressed to high-grade dysplasia and 11.5% (19/165) regressed to normal mucosa. Forty-four patients missed their SE by 6 months or more. Of these, 50% regressed, 40.9% had no change, and 9.1% progressed. Four patients regressed to normal mucosa, one progressed to high-grade dysplasia and none progressed to esophageal adenocarcinoma. Twenty-three patients missed their SE by twice the recommended intervals or more. Of these, 60.9% regressed, 34.8% did not change, and 4.3% progressed. None progressed to esophageal adenocarcinoma or high-grade dysplasia but three regressed to normal mucosa. After adjusting for age and body mass index, patients with low-grade dysplasia are nearly seven times more likely to miss their endoscopy by twice the recommended intervals or more (OR 6.56, P-value 0.03).
Most veteran patients with Barrett's esophagus do not undergo surveillance endoscopies. Veteran patients with Barrett's esophagus undergoing SE rarely progress to high-grade dysplasia or esophageal adenocarcinoma. Veteran patients with Barrett's esophagus who have longer SE up to twice the recommended intervals because they missed their scheduled SE did not have a worse outcome when compared to the general Barrett's esophagus surveillance group. Veteran patients with low-grade dysplasia are most likely to miss their SE by twice the recommended intervals or more, though the reason for this is unknown.
在没有正式监测计划的情况下，确定胃肠病学实践中接受监测的 Barrett 食管患者的随访率、监测期间癌症的发病率以及病理分级的变化。
Barrett 食管是一种癌前病变。建议进行监测性内镜检查（SE），以便早期发现和治疗高级别异型增生和食管腺癌，并预防死亡。SE 并未显示出对死亡率有获益，并且一些研究对其成本效益提出了质疑。大多数胃肠病学实践都没有针对 Barrett 食管的监测计划。少数存在的计划仅在非常专业和资金充足的项目中。在这些结构良好的监测计划之外，关于 Barrett 食管患者的结果的信息很少。
对 1995 年至 2005 年间在退伍军人事务医疗中心诊断和监测的 Barrett 食管患者队列进行回顾性分析。收集了年龄、体重指数和种族的数据。确定并分析了错过 SE 检查 6 个月或更长时间以及错过 SE 检查两次推荐间隔或更长时间的患者的病理分级变化。
共有 472 名患者被诊断为 Barrett 食管或在 1995 年至 2005 年间接受 SE。305 名患者仅接受了一次内镜检查和活检。他们没有进行随访监测性内镜检查和活检。两名患者被排除在最终分析之外：一名在高级别异型增生的指数诊断后接受了食管切除术，一名在最初印象为 Barrett 食管后的两天内被诊断为食管腺癌。有 165 名患有 Barrett 化生或异型增生的患者接受了超过一次 SE，并被纳入最终分析。总体而言，53.3%的患者病理分级没有变化，35.2%的患者病理分级降低，11.5%的患者病理分级升高。无一例（0/165，0%）进展为食管腺癌；3.6%（6/165）进展为高级别异型增生，11.5%（19/165）恢复为正常黏膜。44 名患者错过 SE 检查 6 个月或更长时间。其中，50%的患者病情缓解，40.9%的患者病情无变化，9.1%的患者病情恶化。有 4 名患者恢复到正常黏膜，1 名患者进展为高级别异型增生，没有患者进展为食管腺癌。23 名患者错过 SE 检查两次推荐间隔或更长时间。其中，60.9%的患者病情缓解，34.8%的患者病情无变化，4.3%的患者病情恶化。没有患者进展为食管腺癌或高级别异型增生，但有 3 名患者恢复到正常黏膜。调整年龄和体重指数后，患有低级别异型增生的患者错过内镜检查两次推荐间隔或更长时间的可能性是近七倍（OR 6.56，P 值 0.03）。
大多数退伍军人 Barrett 食管患者不接受监测性内镜检查。接受 SE 的退伍军人 Barrett 食管患者很少进展为高级别异型增生或食管腺癌。错过预定 SE 检查两次推荐间隔或更长时间的 Barrett 食管退伍军人患者的结果与一般 Barrett 食管监测组相比并无恶化。患有低级别异型增生的退伍军人 Barrett 食管患者最有可能错过 SE 检查两次推荐间隔或更长时间，尽管原因尚不清楚。
