Department of Medicine, VA North Texas Healthcare System, and the University of Texas Southwestern Medical Center at Dallas, Dallas, Tex., USA.
Dig Dis. 2014;32(1-2):156-63. doi: 10.1159/000357184. Epub 2014 Feb 28.
Barrett's esophagus, the condition in which metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus, is a complication of gastroesophageal reflux disease (GERD). Metaplasia is a potentially reversible condition, and partial regression of Barrett's metaplasia has been documented with effective medical or surgical therapy for GERD. The important issue for patient management is not whether antireflux treatment causes Barrett's esophagus to regress, but rather whether antireflux therapy prevents cancer in Barrett's esophagus. Proton pump inhibitors (PPIs) would be expected to prevent this cancer because they heal reflux esophagitis, reduce exposure to a potential carcinogen (acid), and might prevent acid-induced proliferation and cancer-promoting cytokine secretion by esophageal epithelial cells. Furthermore, observational studies have shown that PPI use is associated with a decreased incidence of neoplasia in Barrett's esophagus. In theory, successful antireflux surgery, which eliminates the reflux of both acid and bile, should be better for cancer prevention than medical therapy, which only decreases the reflux of acid. However, high-quality studies show no significant difference in cancer incidence between medically and surgically treated patients with GERD and Barrett's esophagus. Furthermore, for individual patients with nondysplastic Barrett's metaplasia, the cancer risk is so small and the number needed to treat for cancer prevention with surgery so large, that it does not matter whether or not surgery provides a tiny margin of extra protection against cancer beyond that provided by medical therapy. The cost and risks of the operation overwhelm any small, additional cancer protective benefit. Antireflux surgery is very effective at controlling the endoscopic signs and symptoms of GERD, but the operation should not be recommended to patients solely with the rationale that it protects against cancer better than medical therapy.
巴雷特食管是一种癌前病变，其特征是化生的柱状上皮取代正常的远端食管鳞状上皮，这是胃食管反流病（GERD）的一种并发症。化生是一种潜在可逆转的状态，已有文献报道，通过对 GERD 进行有效的药物或手术治疗，可以使巴雷特食管的化生部分消退。对于患者管理来说，重要的问题不是抗反流治疗是否会使巴雷特食管消退，而是抗反流治疗是否能预防巴雷特食管的癌症。质子泵抑制剂（PPIs）有望预防这种癌症，因为它们可以治愈反流性食管炎，减少潜在致癌物质（酸）的暴露，并可能通过食管上皮细胞抑制酸诱导的增殖和促进癌症的细胞因子分泌。此外，观察性研究表明，PPI 的使用与巴雷特食管中肿瘤发生率的降低有关。从理论上讲，成功的抗反流手术（既消除胃酸反流，又消除胆汁反流）在预防癌症方面应该优于药物治疗（仅减少胃酸反流）。然而，高质量的研究表明，在接受 GERD 和巴雷特食管治疗的患者中，药物治疗和手术治疗在癌症发病率方面没有显著差异。此外，对于非异型增生性巴雷特食管化生的个体患者，其癌症风险很小，且需要手术治疗的人数众多，因此，手术是否能在药物治疗的基础上提供微小的额外癌症预防保护作用并不重要。手术的成本和风险远远超过了手术在癌症预防方面带来的任何微小的额外益处。抗反流手术在控制 GERD 的内镜症状方面非常有效，但不应仅基于其比药物治疗更能预防癌症的理由，向患者推荐该手术。
