Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif 90033, USA.
J Thorac Cardiovasc Surg. 2011 Jan;141(1):39-47. doi: 10.1016/j.jtcvs.2010.08.058. Epub 2010 Nov 5.
Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal adenocarcinoma. New endoscopic approaches allow treatment of these lesions with esophageal preservation. The aim of this study was to compare the outcome of endoscopic therapy with esophagectomy for high-grade dysplasia and intramucosal cancer.
A retrospective review was performed of all patients treated for high-grade dysplasia or intramucosal adenocarcinoma from 2001 to April 2010.
Endoscopic therapy was performed in 40 patients (high-grade dysplasia = 22, intramucosal cancer = 18) and esophagectomy in 61 patients (high-grade dysplasia = 13, intramucosal cancer = 48). Endotherapy consisted of 102 endoscopic resections and 79 mucosal ablations (median 3 interventions per patient). In the endotherapy group, intramucosal cancer was completely resected in all patients. At last assessment, 10 patients have been converted to intestinal metaplasia without dysplasia and 21 to no residual intestinal metaplasia. Five patients have follow-up biopsy procedures pending after recent ablation, and esophagectomy was performed in 3 patients for failed endotherapy. A laparoscopic Nissen fundoplication has been performed in 8 patients after eradication of intestinal metaplasia. Esophagectomy resected the mucosal disease with negative margins in all patients. Compared with esophagectomy, endotherapy was associated with significantly lower morbidity (39% vs 0; P < .0001) and similar survival (94% at 3 years in both groups; median follow-up 34 months after esophagectomy vs 17 months after endotherapy; P = .0026).
Endoscopic therapy for high-grade dysplasia or intramucosal cancer has lower morbidity than an esophagectomy and similar survival during short-term follow-up, but required multiple procedures in most patients. Both therapies are appropriate options, but preservation of the esophagus allows the option of a fundoplication for reflux control, perhaps further improving long-term quality of life.
食管切除术一直是高级别异型增生和黏膜内腺癌的传统治疗方法。新的内镜方法允许保留食管来治疗这些病变。本研究的目的是比较内镜治疗与食管切除术治疗高级别异型增生和黏膜内癌的结果。
回顾性分析 2001 年至 2010 年 4 月期间所有接受高级别异型增生或黏膜内腺癌治疗的患者。
内镜治疗 40 例（高级别异型增生 22 例，黏膜内癌 18 例），食管切除术 61 例（高级别异型增生 13 例，黏膜内癌 48 例）。内镜治疗包括 102 例内镜切除术和 79 例黏膜消融术（中位数每位患者 3 次干预）。在内镜治疗组中，所有患者的黏膜内癌均完全切除。最后评估时，10 例患者已转化为无异型增生的肠上皮化生，21 例患者无残留肠上皮化生。最近消融后有 5 例患者等待活检，3 例因内镜治疗失败而行食管切除术。8 例肠上皮化生消除后行腹腔镜 Nissen 胃底折叠术。食管切除术切除黏膜病变，切缘均为阴性。与食管切除术相比，内镜治疗的发病率显著降低（39%对 0；P <.0001），生存率相似（两组 3 年生存率均为 94%；食管切除术中位随访 34 个月，内镜治疗 17 个月；P =.0026）。
内镜治疗高级别异型增生或黏膜内癌的发病率低于食管切除术，短期随访生存率相似，但大多数患者需要多次治疗。两种治疗方法都是合适的选择，但保留食管可以选择胃底折叠术来控制反流，可能进一步提高长期生活质量。
