Laparoscopic Transgastric Esophageal Mucosal Resection for High-Grade Dysplasia

BACKGROUND

High-grade dysplasia of the esophageal mucosa has been shown to be a precursor to adenocarcinoma. In addition to esophagectomy, multiple ablative endoscopic techniques have evolved for the management of this condition. As a surgical alternative to esophagectomy, we describe for the first time a new option in the treatment of high-grade dysplasia.

MATERIALS AND METHODS

Two patients with a history of gastroesophageal reflux disease (GERD) underwent upper gastrointestinal endoscopy which demonstrated high-grade dysplasia of the distal esophagus. The first patient had a short segment (0.5-1.0 cm), and the second patient had a longer (2 cm) segment of dysplasia. The patient is placed in the modified lithotomy position. Five trocars are placed as if to perform a fundoplication. A complete circumferential mobilization of the esophagus is performed. The short gastric vessels are divided with the harmonic scalpel, to free up the fundus of the stomach. An anterior horizontal gastrotomy is performed three to four centimeters below the gastroesophageal junction. A solution of epinephrine and normal saline (1:100,000) is injected into the mucosa at the Z-line and, utilizing specially designed hook electrocautery, the mucosa is incised circumferentially around a lighted bougie. Using blunt dissection the mucosa is undermined, elevated, and excised in four quadrants. Three centimeters of the distal esophageal mucosa are resected. The gastrotomy is then closed using a linear stapler, and a 360 degrees fundoplication is performed around a 50 Fr bougie.

RESULTS

High-grade dysplasia was identified in the specimens from both patients; however, neither patient was found to have carcinoma in situ or invasive esophageal cancer. Our first patient has been followed for twenty months, the second for ten months. Both patients underwent routine upper gastrointestinal endoscopy for surveillance of the healing process. At eight months, the mucosa of the first patient showed complete regeneration of squamous epithelium. Our most recent patient appears to be progressing without complications and has also demonstrated normal squamous epithelium at ten months postoperatively, without changes of Barrett's epithelium.

CONCLUSION

The technique of laparoscopic transgastric esophageal mucosal resection is feasible and may be proven to be an alternative to esophagectomy for the management of high-grade dysplasia.

Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Endoscopic screening and periodic surveillance for patients with Barrett's esophagus has been shown to be cost-effective in patients with esophageal dysplasia, with treatment for esophageal cancer limited to esophagectomy. Most gastroenterologists refer patients with high-grade dysplasia for esophagectomy, and effective endoscopic therapies are available for nonoperative patients with esophageal cancer. The cost-effectiveness of screening strategies that incorporate these nonsurgical treatment modalities has not been determined.

METHODS

We designed a Markov model to compare lifetime costs and life expectancy for a cohort of 50-year-old men with chronic reflux symptoms. We compared 10 clinical strategies incorporating combinations of screening and surveillance protocols (no screening, screening with periodic surveillance for both dysplastic and nondysplastic Barrett's esophagus, or periodic surveillance for dysplasia only), treatment for high-grade dysplasia (esophagectomy or intensive surveillance), and treatment for cancer (esophagectomy or surgical and endoscopic treatment options).

RESULTS

Screening and surveillance of patients with both dysplastic and nondysplastic Barrett's esophagus followed by esophagectomy for surgical candidates with high-grade dysplasia or esophageal cancer and endoscopic therapy for cancer patients who were not operative candidates cost $12,140 per life-year gained compared to no screening. Other screening strategies, including strategies that had no endoscopic treatment options, were either less effective at the same cost, or equally effective at a higher cost.

CONCLUSIONS

The cost-effectiveness of screening and subsequent surveillance of patients with dysplastic as well as nondysplastic Barrett's esophagus followed by endoscopic or surgical therapy in patients who develop cancer compares favorably to many widely accepted screening strategies for cancer.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation: a prospective study after fundoplication

The aim of the prospective clinical study presented here is to test the effectiveness of a multimode approach consisting of argon plasma coagulation combined with laparoscopic fundoplication in the management of Barrett's esophagus. Argon plasma coagulation was performed in 19 patients with Barrett's esophagus who had previously undergone surgical antireflux treatment. The mean follow-up time was 17 months, ranging between 6 and 27 months. Squamous epithelium was completely restored in all patients. In 68.4% of cases two sessions were required. The most frequent complications were chest discomfort and retrosternal pain. In 11 patients the symptoms lasted 3 days and in six cases persisted for a longer period, requiring analgesic medication. Short-term dysphagia and odynophagia were observed in four patients.

Histological analysis of endoscopic resection specimens from 326 patients with Barrett's esophagus and early neoplasia

BACKGROUND AND STUDY AIMS

Endoscopic resection has been recommended as a local curative approach for Barrett's neoplasia, but large series are still rare. In the present study we analyzed the histological characteristics of endoscopic resection specimens of Barrett's neoplasia.

PATIENTS AND METHODS

742 endoscopic resection specimens obtained from 326 patients were assessed. The following histological characteristics were evaluated: type of neoplasia, grade of differentiation, depth of infiltration, invasion into lymphatic and blood vessels, and resection status (tumor-free margins were regarded as indicating R0 status).

RESULTS

31 patients had no neoplasia and were excluded from the analysis. Among the remaining 295 patients (711 resection specimens), histological findings were: low-grade intraepithelial neoplasia, 1.0 %; high-grade intraepithelial neoplasia, 2.7 %; and mucosal carcinoma 80.3 %. Carcinomas infiltrating the submucosal layer were rare (sm1 7.5 %; sm2 3.7 %; sm3 4.8 %), as were those invading lymph vessels (3.5 %), and there were none with venous invasion. Most of the carcinomas were well-differentiated (72.2 %), and many of these (92.7 %) were limited to the mucosa, in contrast to moderately and poorly differentiated carcinomas (73.7 % and 22.7 %, respectively). R0 status was achieved in 74.5 % of patients; in 47.8 % this was after repeated endoscopic resection. In 26.8 % of patients, R0 resection was achieved at the first attempt.

CONCLUSIONS

Our study demonstrates that early Barrett's neoplasms removed by endoscopic resection are mostly limited to the mucosa, are well to moderately differentiated, and very rarely show invasion of the lymph or blood vessels. Although these lesions seem to be low risk with regard to metastatic spread and therefore treatable endoscopically, improved endoscopic resection methods for achieving one-piece (en bloc) R0 resection should be developed.

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS

Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium.

PATIENTS AND METHODS

A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later.

RESULTS

Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %).

CONCLUSIONS

Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.

Histological inflammatory changes after surgery at the epithelium of the distal esophagus in patients with Barrett's esophagus: a comparison of two surgical procedures

There are many reports concerning the surgical treatment of patients with Barrett's esophagus, but very few focus on histological changes of inflammatory cells in squamous and columnar epithelium before and late after classic antireflux or acid suppression-duodenal diversion surgery. We evaluate the impact of these procedures in the presence of intestinal metaplasia, dysplasia and Helicobacter pylori in the columnar epithelium. Two groups of patients were studied, 37 subjected to classic antireflux and 96 to acid suppression-duodenal diversion operations. They were subjected to endoscopic and histological studies before and at 1, 3 and more than 5 years after surgery. Manometric evaluations and 24 h pH monitoring were performed before and at 1 year after surgery. The presence of inflammatory cells at both the squamous and columnar epithelium was significantly higher at the late follow up in patients subjected to classic antireflux surgery compared with patients subjected to acid suppression-duodenal diversion operations (P < 0.02 and P < 0.001, respectively). Intestinal metaplasia, present in 100% of patients before surgery, had decreased significantly at 3 years after surgery in patients subjected to acid suppression-duodenal diversion operations compared with classic antireflux procedures, 75% versus 53%, respectively (P < 0.001). The presence of Helicobacter pylori did not vary before or after surgery in either group. In conclusion, acid suppression-duodenal diversion operations are followed by a decreased presence of inflammatory cells in both squamous and columnar epithelium compared with classic antireflux surgery in patients with Barrett's esophagus. Intestinal metaplasia and dysplasia and inflammation findings were also less common after acid suppression-duodenal diversion operation.

[The experience of diagnostic and surgical treatment of Barrett's oesophagus]

There were analyzed five-year late results of prospective investigation on surgical treatment of 23 patients, suffering long-segment Barrett's esophagus (BE). Esophagoplasty and esophagocardioplasty was performed in 7 (30.4%) patients and total fundoplication in combination with endoscopic ablation of metaplastic epithelium--in 16 (69.6%). Excellent and good results marks in 19 (827%) of patients, including those with antireflux operation, and satisfactory--in 4 (17.3%), witnessing high efficacy of surgical treatment in the BE correction.

Long-term clinical and pathologic response of Barrett's esophagus after antireflux surgery

BACKGROUND

The impact of antireflux surgery on outcome in Barrett's esophagus, in particular its effect on both the regression of metaplasia and the progression of metaplasia through dysplasia to adenocarcinoma, remains unclear. This long-term follow-up study evaluated clinical, endoscopic, histopathologic, and physiologic parameters in patients with Barrett's esophagus who underwent antireflux surgery in a specialist unit.

METHODS

Between 1985 and 2001, 58 patients with Barrett's esophagus (49 long-segment and 9 short-segment) underwent a Rossetti-Nissen fundoplication, 32 via open procedure and 26 laparoscopically. Symptomatic follow-up with a detailed questionnaire was available in 58 (100%) and follow-up endoscopy and histology in 57 (98%) patients, and 41 patients (71%) underwent preoperative and postoperative 24-hour pH monitoring.

RESULTS

At a median follow-up of 59 months, 52 patients (90%) had excellent symptom control, whereas 6 patients (10%) had significant recurrent symptoms and were on regular proton pump inhibitor medication. Seventeen of 41 patients having preoperative and postoperative pH monitoring (41%) had a persistent increase of acid reflux above normal. Thirty-five percent (20 of 57) of patients showed either partial or complete regression of Barrett's epithelium. Six of 8 patients with preoperative low-grade dysplasia showed evidence of regression. Dysplasia developed after surgery in 2 patients, and 2 patients developed adenocarcinoma at 4 and 7 years after surgery. All 4 of these patients had abnormal postoperative acid scores.

CONCLUSIONS

Nissen fundoplication provides excellent long-lasting relief of symptoms in patients with Barrett's esophagus and may promote regression of metaplasia and dysplasia. Control of symptoms does not concord fully with abolition of acid reflux. Progression of Barrett's to dysplasia and tumor was only evident in patients with abnormal postoperative acid scores, suggesting that pH monitoring has an important role in the follow-up of surgically treated patients.

Laparoscopic inversion esophagectomy: simplifying a daunting operation

Minimally invasive esophageal resection is a technically demanding procedure that may reduce patient morbidity and improve convalescence when compared with the open approach. Despite these proposed advantages, the minimally invasive approach has not been widely embraced and is routinely performed in only a few specialized centers around the world. The laparoscopic inversion esophagectomy attempts to eliminate some of the technical obstacles inherent in this procedure by simplifying the transhiatal mediastinal dissection, facilitating vagal preservation, and enhancing safety. We present a case of a 37-year-old man who underwent laparoscopic inversion esophagectomy for Barrett's esophagus with high-grade dysplasia. Immediate and long-term outcome measures are being prospectively gathered in order to establish the ultimate value of this procedure.

Adenocarcinoma appearing very late after antireflux surgery for Barrett's esophagus: long-term follow-up, review of the literature, and addition of six patients

Antireflux surgery is supposed to prevent the development of adenocarcinoma in patients with Barrett's esophagus. The purpose of this study was to determine the prevalence of adenocarcinoma late after antireflux surgery. A total of 161 patients with long-segment Barrett's esophagus had antireflux surgery and were followed for a mean of 148 months (range 54 to 268 months) Clinical, endoscopic, histologic, and functional studies were performed. Of the original 161 patients, 147(91.3%) completed long-term follow-up. Six patients (4.1%) developed adenocarcinoma 4,5,6,9,17, and 18 years, respectively, after surgery. Five were men. Two of them were asymptomatic for 12 and 17 years. Three of them had extra-long-segment Barrett's esophagus. Five underwent manometric evaluation with only one showing an incompetent lower esophageal sphincter. In two cases, 24-hour pH studies showed massive acid reflux. Two patients had early adenocarcinoma, whereas four had advanced carcinoma. Adenocarcinoma in long-segment Barrett's esophagus seems to develop mainly in patients with recurrence of pathologic reflux, especially among men. A review of the English language literature during the last 23 years found 25 articles dealing with Barrett's esophagus and antireflux surgery. Most of these reports had only a few patients with short-term follow-up (<60 months). To determine the true prevalence of this complication, a long-term objective follow-up is necessary.

Chronology of the Barrett's metaplasia-dysplasia-carcinoma sequence

The objective of this study was to assess the course over time of the Barrett's metaplasia-dysplasia-carcinoma sequence. The method used was a retrospective analysis of the medical records of a patient series with a median follow-up of 25 months. The study was undertaken in a university hospital foregut laboratory. The progress of seven patients was followed through the sequence of Barrett's esophagus, low-grade dysplasia and high-grade dysplasia to cancer. They all underwent subsequent esophagectomy and were found to have intramucosal adenocarcinoma. The main outcome measure was the time from the first diagnosis of intestinal metaplasia to the development of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. Low-grade dysplasia developed in a median of 24 months, high-grade dysplasia after a median of 33 months and cancer after 36 months. All patients underwent esophagectomy with reconstruction and no patient has had a recurrence at a median follow-up of 25 months (range 10-204 months). Patients on Barrett's surveillance who develop early esophageal adenocarcinoma did so within approximately 3 years after the diagnosis of non-dysplastic Barrett's esophagus.

Endoscopic therapy of Barrett's: what more do we need to know?

Results emerging from endoscopic treatments to ablate Barrett's oesophagus indicate that APC alone or ALA-PDT in combination with APC achieves complete clearance of Barrett's epithelium in approximately two thirds of patients.

A laparoscopy-assisted surgical approach to esophageal carcinoma

BACKGROUND

Surgical resection is the treatment of choice for esophageal carcinoma. Over the past decade, laparoscopy has proven an accurate staging modality for detecting peritoneal carcinosis and small metastatic liver deposits unsuspected at preoperative investigation. This has led to a change in surgical strategy in up to 20% of patients. In addition, by means of laparoscopic techniques, it is possible to mobilize the stomach and perform a safe transhiatal mediastinal dissection at least up to the level of the inferior pulmonary veins.

PATIENTS AND METHODS

Laparoscopy-assisted esophagectomy was attempted in 43 patients over the past 3 years. The esophagectomy was performed via laparoscopy combined with right thoracotomy (group A) or with left cervicotomy and transmediastinal endodissection (group B).

RESULTS

The overall conversion rate to laparotomy was 11.6%. No hospital deaths occurred. The morbidity rate was 20% in group A and 30.7% in group B. The mean hospital stay was 11 in group A and 10 days in group B. Five patients died between 11 and 19 months after surgery with recurrent disease. No port-site metastases were recorded during follow-up.

CONCLUSIONS

This approach has proven feasible and safe in the medium-term follow-up. Further experience and a longer follow-up are needed to assess the impact of these procedures on long-term survival.

Barrett's esophagus: best of Digestive Disease Week 2003

The definition of Barrett's esophagus is conceptually simple. It is the replacement of the normal squamous mucosa by specialized intestinal metaplasia within the esophagus. Barrett's esophagus would only be a clinical curiosity if not for its predisposition toward neoplastic change. In spite of all the knowledge and data gathered thus far on Barrett's, much remains unknown. Why do some patients develop Barrett's while others do not? Why do some with Barrett's advance to adenocarcinoma? Once Barrett's develops, what is the optimal prevention strategy for adenocarcinoma? These clinical unknowns touch only the tip of the iceberg and have made Barrett's esophagus a subject of intense research. This review offers some of the highlights from Digestive Disease Week 2003, comprised of posters of distinction and oral presentations.

[The influence of Barrett's esophagus on the clinical signs and postoperative results of GERD]

AIM OF THE STUDY

Was to estimate the influence of the Barrett's esophagus on the clinical signs and post-surgical results of the GERD.

PATIENTS AND METHODS

Within 1998-2001 193 patients have been operated upon in our clinic due to GERD, 81 male and 112 female. Mean patient age was 55 years (from 16 to 84 years). All patients had complaints on heartburn and regurgitation. We assessed the severity of heartburn, regurgitation, dysphagia with the help of a special scale ranging from 1 (absence of symptoms) to 5 (most severe symptoms). All patients underwent gastric and esophageal radiological investigation with barium contrast as well as esophago-gastro-duodenoscopy (EGDS) with biopsy. In 190 cases esophageal hernia was found. The reflux-esophagitis was classified according to Savary-Miller after endoscopic examination. Esophagitis of degree I-III was diagnosed presurgically in 176 cases, Barrett's esophagus in 16 (9.1%) cases. In 13 cases we found a short metaplastic segment (< 3 cm), in 3 cases a long segment (> 3 cm). In 15 cases we found metaplasia without dysplasia, in 1 case low-grade dysplasia. In order to assess the presence of BM influence on presurgical clinical signs, the severity of esophagitis, and the regression rate of symptoms after surgery, we divided the patients into two groups and compared them: group I (with Barrett's metaplasia), and group II (without Barrett's metaplasia). All patients underwent laparoscopic Nissen or Toupet fondoplications. For group I patients we performed 14 Nissen and 2 Toupet procedures, in group II 148 Nissen and 29 Toupet interventions. The regression of clinical and endoscopic symptoms was assessed 6 months after surgery by re-questioning the patients and with the help of EGDS. In cases of Barrett's esophagus endoscopic biopsies from all 4 esophageal segments were performed. The patients of group I were followed-up by performing EGDS every 6 months. The mean follow-up period after surgery was 28 months.

RESULTS

No statistically significant difference was found when comparing the groups for age (group I--59/SD 11, and group II--54/SD 13.2), gender, disease duration (group I--13.2/SD 13.7 years, group II--8.2/SD 10.5 years), radiologically determined hernial size or preoperative severity of esophagitis. The regression of the severity of heartburn and regurgitation was prominent in both groups with no significant difference between the groups. Dysphagia before and after surgery was comparable in both groups. Esophagitis confirmed by EGDS remained in 3 of 16 cases in group I and in 9 of 164 cases in group II. The metaplastic changes in group I were followed every 6 months for 16-36 months (mean 28 months). In 13 cases the metaplastic segment demonstrated no changes, it became shorter in 3 cases. We didn't observe any complete regression of metaplasia. In the case with preoperative low grade dysplasia, the length of the segment did not change, we observed neither histological progression or regression.

CONCLUSIONS

Barrett's metaplasia had no influence on the regression of symptoms of GERD and esophagitis after antireflux surgery. No histological progression of Barrett's metaplasia has been observed after antireflux surgery. The EGDS follow-up should not be very frequent in cases of Barrett's esophagus without dysplasia and good postsurgical regression of symptoms.

Barrett's esophagus: the role of laparoscopic fundoplication

BACKGROUND

To review our early operative results and endoscopic findings after laparoscopic fundoplication for Barrett's esophagus (BE).

METHODS

From January 1995 through December 2000, 49 patients with BE (35 men and 14 women) underwent laparoscopic antireflux surgery. Median age was 54 years (range, 28 to 85 years). No patient had high-grade dysplasia; 6, however, had low-grade dysplasia. All 49 patients had gastroesophageal reflux symptoms. Heartburn was present in 41 patients (84%), dysphagia in 16 (33%), epigastric or chest pain in 9 (18%), and other symptoms in 16 (33%). A Nissen fundoplication was performed in 48 patients and a partial posterior fundoplication in 1. Forty-one patients (84%) had concomitant hiatal hernia repair.

RESULTS

There were no deaths. Complications occurred in 2 patients (4%). Follow-up was complete in 48 patients (98%) and ranged from 1 to 81 months (median, 29 months). Functional results were classified as excellent in 33 patients (69%), good in 9 (19%), fair in 5 (10%), and poor in 1 (2%). Thirty-three patients (67%) underwent postoperative surveillance esophagoscopy with biopsy. Nine patients (18%) had total regression of BE and 3 (6%) had a decrease in total length. In the 6 patients with preoperative low-grade dysplasia, dysplasia was not found in 4, remained unchanged in 1, and progressed to in situ adenocarcinoma in 1.

CONCLUSIONS

Laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE may occur in some patients, the possibility of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Therefore, endoscopic surveillance should continue.

High-Energy Laser Therapy of Barrett’s Esophagus: Preliminary Results

We present the preliminary results obtained by our research group utilizing Nd:YAG and diode lasers to treat Barrett's esophagus (BE). A total of 15 patients with BE (mean age 58 years) underwent endoscopic laser therapy: 11 with intestinal metaplasia, 2 with low-grade dysplasia, and 2 with high-grade dysplasia. The mean length of BE was 4 cm (range 1-12 cm). Six of these patients also underwent antireflux surgery, and nine were prescribed acid-suppressive medication. Endoscopic Nd:YAG laser treatment was carried out from 1997 to 1999; thereafter, diode laser was employed. The mean follow-up of these patients after the first laser session was 28 months. Patients underwent a mean of 6.5 laser sessions (range 3-17 sessions), with no apparent complications. The mean energy per session was 1705 JJ. Only six of these patients (40%) showed complete endoscopic and histologic remission, but a mean of 77% (SD 23.8%) of the total metaplastic tissue in all these patients was ablated. The percentage of healed mucosa was higher in patients with short-segment BE (92%) ( p < 0.05) and in subjects treated by two or more laser sessions per centimeter of BE length (89%) ( p < 0.05). All four patients with dysplasia showed histologic regression to nondysplastic BE or to squamous epithelium, without recurrence during a mean follow-up of 30 months. The patients who underwent antireflux surgery and those prescribed pharmacologic treatment had similar results. Nd:YAG and diode laser treatment of BE is a safe, effective procedure; it required two sessions per centimeter of metaplasia; and it achieved complete regression of the dysplasia. Further studies are necessary to quantify its effect on cancer incidence.

[Barrett's esophageal adenocarcinoma]

Barrett's esophageal adenocarcinoma arises in Barrett's epithelium, which is grouped with gastro-esophageal reflux disease (GERD). Although the incidence of esophageal adenocarcinoma is very low in eastern countries, including Japan, it has been increasing markedly and is similar to that of squamous cell carcinoma in the western countries. Surveillance, endoscopic treatment, and chemoprevention using COX-2 inhibitors have recently been developed for dysplasia or mucosal cancer in Barrett's esophagus. Barrett's esophageal adenocarcinoma is diagnosed by endoscopy and by biopsy specimens pathologically. Surgical resection has been a mainstream treatment but definitive or neoadjuvant chemoradiotherapy has recently been performed.

Surgical treatment of Barrett's esophagus: 1980-2003

Barrett's esophagus is a complication of long-standing gastroesophageal reflux and can be a premalignant condition. The goals of surgical treatment, which were well summarized by DeMeester, have been increased and more detailed by us. They consist of (1) controlling symptoms of gastroesophageal reflux disease; (2) abolishing acid and duodenal reflux into the esophagus; (3) preventing or eliminating the development of complications; (4) preventing extension of or an increase in the length of intestinal metaplasia; (5) inducing regression of intestinal metaplasia to the cardiac mucosa; and (6) preventing progression to dysplasia, thereby inducing regression of low-grade dysplasia and avoiding the appearance of an adenocarcinoma. We have reviewed 25 articles in the English-language literature published from 1980 to 2003 dealing specifically with the surgical treatment of Barrett's esophagus. In most of these papers too few patients were included, the follow-up was less than 60 months, and the clinical success deteriorated with time. Acid reflux persists after surgery in nearly 35% of Barrett's esophagus patients; and at 10 years after surgery duodenal reflux is present in 95%. Peptic ulcer, stricture, and erosive esophagitis are present in 15% to 30% late after surgery, and in 16% there is progression of the intestinal metaplasia. There is the appearance of low-grade dysplasia in 6.0% and adenocarcinoma in 3.4%, and there is regression of low-grade dysplasia in 45.0%. These results challenge the arguments supporting antireflux surgery for patients with Barrett's esophagus: The clinical results are not optimal, no long-lasting effect has been demonstrated, and it does not prevent the appearance of dysplasia or adenocarcinoma. An excellent alternative is acid suppression and a duodenal diversion procedure, which has had 91% clinical success for more than 5 years. This regimen has almost eliminated acid and duodenal reflux, and there has been no progression to dysplasia or adenocarcinoma. Moreover, in 60% of the patients with low-grade dysplasia, regression to nondysplastic mucosa has occurred.

Barrett's esophagus: histopathologic definitions and diagnostic criteria

Adenocarcinoma of the distal esophagus is rising more rapidly in incidence than any other visceral malignancy in the Western world. It is well established that most, if not all, of these tumors develop in Barrett's esophagus via the metaplasia-dysplasia-carcinoma sequence and could theoretically be detected at an early stage, but despite this, the majority of these tumors are still detected late in their course. This highlights the fact that the goal of effective surveillance for patients at risk for developing an adenocarcinoma of the distal esophagus is still far off. In addition, adenocarcinomas of the esophagogastric junction and gastric cardia are also rising in incidence, but their carcinogenesis and their relation to Barrett's esophagus are still being defined, as are the meaning and significance of the relatively new entities "short-segment Barrett's" and "ultra-short-segment Barrett's". This review attempts to clarify the main histopathologic issues concerned with the definition of Barrett's esophagus, its distinction from intestinal metaplasia of the gastric cardia, as well as the criteria for the histologic diagnosis of dysplasia and carcinoma in Barrett's esophagus.

Factors influencing the development of Barrett's epithelium in the esophageal remnant postesophagectomy

BACKGROUND

Barrett's esophagus results from chronic reflux of both acid and bile. Reflux of gastric and duodenal contents is facilitated through the denervated stomach following esophagectomy, but the development of Barrett's changes in this model and the relationship to gastric and esophageal physiology is poorly understood.

AIMS

To document the development of new Barrett's changes, i.e., columnar metaplasia or specialized intestinal metaplasia (SIM) above the anastomosis, and relate this to the recovery of gastric acid production, acid and bile reflux, manometry, and symptoms.

PATIENTS AND METHODS

Forty-eight patients at a median follow-up of 26 months (range = 12-67) postesophagectomy underwent endoscopy with biopsies taken 1-2 cm above the anastomosis. The indication for esophagectomy had been adenocarcinoma (n = 27), high-grade dysplasia (n = 2), and squamous cell cancer (n = 19). Physiology studies were performed in 27 patients and included manometry (n = 25), intraluminal gastric pH (n = 24), as well as simultaneous 24-hour esophageal pH (n = 27) and bile monitoring (n = 20).

RESULTS

Duodenogastric reflux increased over time, with differences between patients greater than and less than 3 years postesophagectomy for acid (p = 0.04) and bile (p = 0.02). Twenty-four patients (50%) developed columnar metaplasia and of these 13 had SIM. The prevalence of columnar metaplasia did not relate to the magnitude of acid or bile reflux, to preoperative neoadjuvant therapies, or to the original tumor histology. The duration of reflux was most significant, with increasing prevalence over time, with SIM in 13 patients at a median of 61 months postesophagectomy compared with 20 months in the 35 patients who were SIM-negative (p < 0.006). Supine reflux correlated with symptoms.

CONCLUSIONS

The development of Barrett's epithelium is frequent after esophagectomy, is time-related, reflecting chronic acid and bile exposure, and is not specific for adenocarcinoma or the presence of previous Barrett's epithelium. This model may represent a useful in vivo model of the pathogenesis of Barrett's metaplasia and tumorigenesis.