The rationale for esophagectomy as the optimal therapy for Barrett's esophagus with high-grade dysplasia

Abstract

Objective: The authors determined the incidence of invasive adenocarcinoma after esophagectomy in patients endoscopically diagnosed as having Barrett's esophagus with high-grade dysplasia.

Summary background data: Barrett's esophagus is a well-recognized premalignant condition. There is controversy with regard to the optimal treatment of high-grade dysplasia in Barrett's esophagus. Recognizing the morbidity and mortality associated with esophagectomy, some recommend a selective approach, reserving esophagectomy only for evidence of invasive cancer identified through endoscopic surveillance. Other advocate esophagectomy for all suitable operative candidates.

Methods: The authors reviewed their experience between 1985 and 1995 with 11 patients with high-grade dysplasia arising in Barrett's esophagus diagnosed by endoscopic biopsy and treated by esophagectomy.

Results: All patients were white men ranging in age from 47 to 70 years. Ten patients underwent esophagectomy by the Ivor Lewis technique; one had a transhiatal resection. Eight patients (73%) had invasive adenocarcinoma identified after esophagectomy; two (18%) had positive lymph nodes; one required a prolonged hospital stay for an anastomotic leak; two (18%) temporarily suffered delayed gastric emptying. The authors' review identified 85 additional patients previously reported during the same period. Including the current series, 39 patients (41%) had invasive adenocarcinoma identified in the resected specimen. A preponderance of early, potentially curable carcinomas are characteristically found in these patients.

Conclusion: A high incidence of endoscopically undetected invasive carcinoma strongly supports esophagectomy as the preferred approach for suitable operative candidates with high-grade dysplasia in Barrett's esophagus.