Barrett's Esophagus with High Grade Dysplasia: Surgical Results and Long-Term Outcome--An Update
Abstracts
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Objective We updated our surgical results and long-term outcome for prophylactic esophagectomy in patients with Barrett's esophagus and high-grade dysplasia (HGD) and determined the incidence of occult adenocarcinoma. Background We previously published our data (Ann Surg 1996; 224:66-71) on Barrett's esophagus with HGD and strongly recommended an aggressive surgical approach, prophylactic esophagectomy. Numerous other groups have also advocated this approach; however, most studies have only a small number of patients. We have since noted an increase in patients referred with HGD and were interested in examining changes in our patient population and outcomes. Methods Sixty consecutive patients with HGD underwent esophagectomy and had pre-and postoperative pathology examined at our institution from 1982 to 2001. We reviewed medical records to determine patient characteristics, surgical approach, operative morbidity and mortality, pathology, and length of stay. Patients and/or referring physicians were contacted to determine long-term outcome. Results Fifty-three men (88%) and 7 women (12%) were followed up for a median of 4.6 years. Transhiatal esophagectomy was performed in the majority of patients (82%). There were one postoperative death (1.7%) and 15 complications (29%). Median postop length of stay was 9 days. In eighteen patients (30%), invasive adenocarcinoma was detected in the resected specimen. When examined by time periods, 43% (13/30) of patients were diagnosed with occult cancer from 1982-1994, whereas 17% (5/30) harbored occult malignancy from 1994-2001. All patients with adenocarcinoma in the recent interval had stage I disease, as opposed to only 61.5% of patients from the earlier study. Operative mortality declined from 3.3% to 0% over the two intervals as did mean length of stay (from 14 days to 10 days). Five-year survival was excellent at 88%. Age and amount of preoperative weight loss were preoperative predictors of outcome, whereas major postoperative complications and pathologic stage were postoperative predictors. Conclusions Barrett's esophagus with high-grade dysplasia continues to be an indication for prophylactic esophagectomy. Overall prevalence of occult adenocarcinoma remains high. An aggressive surgical approach has led to a declining incidence of occult cancer and treatment of adenocarcinoma at an earlier stage when found. |
