Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
Am J Gastroenterol. 2010 Jun;105(6):1276-83. doi: 10.1038/ajg.2010.1. Epub 2010 Feb 23.
Patients with Barrett's high-grade dysplasia (HGD) or early esophageal adenocarcinoma (EAC) that is shown on biopsy alone continue to undergo esophagectomy without more definitive histological staging. Endoscopic resection (ER) may provide more accurate histological grading and local tumor (T) staging, definitive therapy, and complete Barrett's excision (CBE); however, long-term outcome data are limited. Our objective was to demonstrate the effect on histological grade or local T stage, efficacy, safety and long-term outcome of ER for Barrett's HGD/EAC and of CBE in suitable patients.
This prospective study at two Australian academic hospitals involved 75 consecutive patients over 7 years undergoing ER for biopsy-proven HGD or EAC, using multiband mucosectomy or cap technique. In addition, CBE by 2-3-stage radical mucosectomy was attempted for all Barrett's segments<or=3 cm in length in patients aged<75 years with minimal comorbidities.
Biopsy histology showed HGD in 89% of patients and EAC in 11%. However, ER histology resulted in altered grading or staging in 48% of patients (down 28%, up 20%), with HGD in 53%, low-grade dysplasia (LGD) in 19%, mucosal adenocarcinoma in 13%, submucosal adenocarcinoma in 9%, and no dysplasia in 4% of patients. The CBE success rate was 94%. Complications were one aspiration (hospitalization with full recovery) and six strictures successfully dilated endoscopically. During the mean follow-up of 31 months (range 3-89), there was no recurrence at ER sites, 11% developed metachronous lesions and five patients underwent esophagectomy for ER-demonstrated submucosal invasion. Esophagectomy specimens were T0N0M0 in three and T1N0M0 in two patients. There were no deaths due to adenocarcinoma.
ER alters histological grade or local T stage in 48% of patients and dramatically reduces esophagectomy rates by providing safe and effective therapy. ER has a high success rate (94%) for CBE in short segment Barrett's esophagus.
单独通过活检发现的 Barrett 高级别异型增生（HGD）或早期食管腺癌（EAC）患者仍需进行食管切除术，而不进行更明确的组织学分期。内镜下切除术（ER）可提供更准确的组织学分级和局部肿瘤（T）分期、确定性治疗和完整的 Barrett 切除（CBE）；然而，长期结果数据有限。我们的目的是证明 ER 治疗 Barrett 高级别异型增生/早期食管腺癌的组织学分级或局部 T 分期、疗效、安全性和长期结果的影响，以及在合适患者中 CBE 的效果。
这项在澳大利亚两家学术医院进行的前瞻性研究，纳入了 7 年内 75 例连续接受 ER 治疗的活检证实为 HGD 或 EAC 的患者，使用多带黏膜切除术或帽技术。此外，对于年龄<75 岁且合并症较少、长度<3cm 的所有 Barrett 段，尝试进行 2-3 期根治性黏膜切除术的 CBE。
活检组织学显示 89%的患者为 HGD，11%为 EAC。然而，ER 组织学导致 48%的患者分级或分期改变（降级 28%，升级 20%），其中 53%为 HGD、19%为低级别异型增生（LGD）、13%为黏膜腺癌、9%为黏膜下腺癌和 4%的患者无异型增生。CBE 的成功率为 94%。并发症为 1 例吸入性肺炎（住院并完全康复）和 6 例内镜下成功扩张的狭窄。在平均 31 个月（3-89 个月）的随访期间，ER 部位无复发，11%的患者发生了异时性病变，5 例患者因 ER 显示黏膜下浸润而行食管切除术。食管切除标本中，3 例为 T0N0M0，2 例为 T1N0M0。无腺癌相关死亡。
ER 通过提供安全有效的治疗方法，改变了 48%患者的组织学分级或局部 T 分期，并显著降低了食管切除术的比例。ER 治疗短节段 Barrett 食管的 CBE 成功率高（94%）。
