Department of Surgery, University of Favaloro, Av. Belgrano 1746, C1093AAS, Buenos Aires, Argentina,
World J Surg. 2014 Jan;38(1):96-105. doi: 10.1007/s00268-013-2235-y.
Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario.
Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article.
There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates.
Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.
食管腺癌的治疗常涉及手术切除。介入内镜的新技术使 Barrett 食管早期肿瘤的管理发生了重大转变，包括高级别异型增生（HGD）、黏膜内癌，以及在某些情况下，黏膜下癌。然而，对于这些病例的食管保留指征尚未达成共识。在这项工作中，根据每个病例的临床相关方面（年龄、合并症和社会环境），制定了早期食管肿瘤管理的共识指南。
根据其在大容量中心的背景和临床专业知识，邀请了 17 名专家参与。创建了一个调查问卷，其中包括四个临床情景，涵盖了 HGD 和/或早期食管肿瘤的广泛情况，特别是在可能存在争议的情况下。每个临床情景都可以根据患者年龄（20、50 和 80 岁）进行讨论。为每个临床情景选择了一位专家来捍卫该立场。每个辩护都引发了共识会议期间的后续讨论。讨论的结论以及伴随的文献分析使专家能够确认或改变他们的原始选择，并为本文所述建议提供依据。
支持 HGD 患者食管保留的意见完全一致，与患者年龄或 Barrett 长度无关。对于 T1a 腺癌患者，年轻和中年患者的保留意见不一致（65%），但老年患者支持（100%）。对于 T1b 腺癌，手术切除的共识达成（90%），为淋巴结侵犯风险低或手术候选者差的患者保留器官。
内镜成像和治疗的进步允许在大多数早期食管肿瘤的情况下保留器官，前提是患者了解这一决定的影响。
