DeMeester T R, Attwood S E, Smyrk T C, Therkildsen D H, Hinder R A
Creighton University School of Medicine, Department of Surgery, Omaha, Nebraska.
Ann Surg. 1990 Oct;212(4):528-40; discussion 540-2. doi: 10.1097/00000658-199010000-00015.
Seventy-six patients with Barrett's esophagus were cared for during a 10-year period. Fifty-six patients (74%) presented with complications of the disease. There were 20 strictures, 7 giant ulcers, 11 cases of dysplasia, and 29 patients with carcinoma. In patients with benign disease, 93% had mechanically defective sphincters and 83% had peristaltic failure of the lower esophageal body. Esophageal pH monitoring showed excessive esophageal exposure to pH less than 4 in 93% and excessive exposure to pH more than 7 in 34% of the patients tested. Ninety-three per cent of patients with excessive alkaline exposure had complications, compared to only 44% with normal alkaline exposure (p less than 0.01). Gastric pH monitoring, serum gastrin levels, and gastric acid analysis supported a duodenal source for the alkaline exposure. Antireflux surgery was performed using Nissen fundoplication in 30, Belsey partial fundoplication in 3, and Collis-Belsey gastroplasty in 2. Six required resection with colon interposition. Good symptomatic control was achieved in 77% after antireflux surgery. Four patients had symptoms and signs of duodenogastric reflux; three required a bile diversion procedure. Fifteen patients had an en bloc curative resection with colon interposition. One patient with high-grade dysplasia on biopsy was found to have intramucosal carcinoma after simple esophagectomy. Five tumors were intramucosal, seven were intramural, and four were transmural. Lymph node involvement occurred only in the latter two. Actuarial survival 5 years after curative resection was 53%. Median survival time for patients after palliative resection or no resection was 12 months. Study of en bloc specimens indicated that extent of resection should be adapted to extent of disease: esophagectomy for intramucosal disease, en bloc esophagectomy with splenic preservation for intramural and transmural disease. Serum CEA was useful in detecting recurrent disease after surgery when the primary tumor stained positively for CEA.
在10年期间共护理了76例巴雷特食管患者。56例（74%）出现了该病的并发症。其中有20例狭窄、7例巨大溃疡、11例发育异常以及29例癌症患者。在患有良性疾病的患者中，93%存在机械性缺陷的括约肌，83%存在食管下段蠕动功能衰竭。食管pH监测显示，93%的受测患者食管暴露于pH值低于4的环境中时间过长，34%的患者食管暴露于pH值高于7的环境中时间过长。碱性暴露过度的患者中有93%出现并发症，而碱性暴露正常的患者中只有44%出现并发症（p<0.01）。胃pH监测、血清胃泌素水平及胃酸分析均支持碱性暴露源于十二指肠。30例行nissen胃底折叠术、3例行Belsey部分胃底折叠术、2例行Collis-Belsey胃成形术进行抗反流手术。6例需要行结肠代食管切除术。抗反流手术后77%的患者症状得到良好控制。4例患者有十二指肠胃反流的症状和体征；3例需要行胆汁转流手术。15例患者行整块根治性切除并结肠代食管术。1例活检显示高级别发育异常的患者在单纯食管切除术后被发现患有黏膜内癌。5例肿瘤为黏膜内型，7例为壁内型，4例为透壁型。仅后两种类型出现淋巴结转移。根治性切除术后5年的实际生存率为53%。姑息性切除或未切除患者的中位生存时间为12个月。对整块标本的研究表明，切除范围应根据疾病范围进行调整：黏膜内疾病行食管切除术，壁内型和透壁型疾病行保留脾脏的整块食管切除术。当原发肿瘤CEA染色呈阳性时，血清CEA有助于检测术后复发疾病。
