Centre of Gastroenterology, Klinik Hirslanden, Witellikerstrasse 40, 8008, Zurich, Switzerland.
Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.
Dig Dis Sci. 2018 Aug;63(8):2146-2154. doi: 10.1007/s10620-018-5158-5.
Barrett's esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion ≤ 500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett's epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated.
伴有高级别异型增生和早期腺癌的 Barrett 食管可通过内镜下切除进行根治性治疗。组织病理学相关性研究已确立，黏膜癌发生淋巴结转移的风险极小，且可长期获得完全缓解。虽然一旦发生黏膜下浸润，手术是金标准治疗方法，但即使 T1sm1（黏膜下浸润 ≤ 500μm）且无淋巴结转移额外危险因素的病例，也可能通过内镜下切除获得治愈。内镜下切除首先是一种初始诊断程序，一旦组织病理学评估确认符合治愈标准，就将其视为治愈性切除。内镜下切除可通过内镜黏膜切除术来实现，尽管这种方法操作简单，风险相对较低，但对于直径超过 1.5cm 的病变，无法实现整块切除。相比之下，内镜黏膜下剥离术技术要求更高，并发症风险更大，但能够实现直径超过 1.5cm 的病变整块切除。在某些特定情况下，如怀疑黏膜下浸润和病变直径超过 1.5cm 时，内镜黏膜下剥离术尤为重要。在其他情况下，由于内镜下切除通常与射频消融联合用于消融剩余的 Barrett 上皮，因此只需分片内镜黏膜切除术，因为任何残留的浅层不可见异型增生都会被消融。
