The management of high grade dysplasia and early cancer in Barrett's esophagus. A multidisciplinary problem.

BACKGROUND

The incidence of Barrett's-associated esophageal adenocarcinoma is rising, but experience in the treatment of high-grade dysplasia (HGD) or early cancer is limited. Based on an endoscopic surveillance program, the authors developed a systematic multidisciplinary approach to this problem.

METHODS

Surgical resection was considered if biopsies of the Barrett's segment, performed according to a published protocol, showed invasive cancer, intramucosal carcinoma, or repeated evidence of HGD. The type of resection was based on the length of the Barrett's segment and included an en bloc lymph node dissection for staging purposes. Careful intraoperative pathologic evaluation ensured that all of the Barrett's mucosa was resected.

RESULTS

From 1984 to 1993, 27 consecutive patients (23 men, 4 women), with median age of 61 years (range, 45-75 years) underwent surgical exploration. Indications for operation were invasive cancer in 17 patients, intramucosal carcinoma in 5 patients, and HGD in 5 patients. Median length of the Barrett's segment was 9 cm (range, 1-17 cm). Only 15 patients (55%) had abnormalities visible with endoscopic examination that were potentially suspicious for malignancy. Twenty-six patients underwent resection with complete removal of the Barrett's mucosa, 20 by Ivor Lewis esophagogastrectomy, and 6 by transhiatal esophagectomy. Pathologic tumor stages were: TisN0M0 in 10 patients; T1N0M0 in 11 patients; T2N0M0 in 2 patients; T3N0M0 in 3 patients; and T1NXM1 in 1 patient. There were no postoperative deaths or anastomotic leaks. Major complications occurred in 4 patients. With a median follow-up of 3.7 years, 22 patients were alive, and only 2 patients had recurrences.

CONCLUSIONS

This increasingly important group of patients with HGD or early carcinoma in the Barrett's esophagus has a high chance of cure but requires careful multidisciplinary treatment by the surgeon, gastroenterologist, and pathologist.