Gastroenterology

Gastroenterology

Volume 120, Issue 7, June 2001, Pages 1607-1619
Gastroenterology

Alimentary Tract
Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia*,**

https://doi.org/10.1053/gast.2001.25065Get rights and content

Abstract

Background & Aims: Surgical resection of the esophagus is frequently recommended for Barrett's high-grade dysplasia (HGD) without cancer. Methods: During a 20-year period, patients were diagnosed and observed through an organized surveillance program at the Hines Veterans Affairs Hospital. The program was supported by Hines VA and organized and managed by 2 endoscopists using preestablished endoscopic criteria. Results: Barrett's esophagus was diagnosed in 1099 patients, and 36,251 esophageal mucosal specimens were reviewed. Seventy-nine of 1099 patients (7.2%) initially had HGD (34 prevalent) or subsequently developed HGD (45 incident) without evidence of cancer. Of the 75 HGD patients who remained without detectable cancer after the 1 year of intensive searching, 12 developed cancer (16%) during a mean 7.3-year surveillance period: 11 of the 12 who were compliant were considered cured with surgical or ablation therapy. Cancer did not develop in the remaining 63 HGD patients during the surveillance period. Conclusions: HGD without cancer in Barrett's esophagus follows a relatively benign course in the majority of patients. In the patients who eventually progress to cancer during regular surveillance, surgical resection is curative. Surveillance endoscopies with biopsy is a valid and safe follow-up strategy for Barrett's patients who have HGD without cancer.

GASTROENTEROLOGY 2001;120:1607-1619

Section snippets

The program

From January 1979 to July 1996, patients with Barrett's esophagus were diagnosed in the ambulatory outpatient endoscopy clinic at Hines Veterans Affairs Hospital, Hines, Illinois. The clinic developed an organized patient recall system and used a full-time computer data entry person. From July 1996 through June 2000, screening and surveillance were continued in the combined inpatient/outpatient endoscopy clinic.

Endoscopy protocol

Patients with HGD underwent endoscopies and biopsies that were performed by 1 of 2

Results

During the 20 years of screening and surveillance, 1099 patients had Barrett's esophagus ranging from no dysplasia to cancer, and 26 patients had cancer of the gastroesophageal junction (non–Barrett's esophagus). Figure 2 shows the distribution of the 1125 patients at their current most advanced stage of dysplasia.

. The entire high-risk population: Hines Veterans Affairs. Distribution of the 1125 patients at their current most advanced dysplasia. Of the 1125 patients, 1099 had Barrett's

Discussion

Based on the results of our 20 years of screening, surveillance, and follow up of 75 patients with HGD existing alone, we suggest that the recommendation for esophagectomy in patients with HGD be reconsidered. Indeed, during surveillance for up to 13.9 years, only 12 (16%) eventually developed cancer. Eleven of the 12 patients complied with appropriate surveillance; 10 of the 11 had curable early cancer (only 1 patient had greater than stage I cancer but was still cured), and 1 refuses

Conclusions

We conclude that in patients with Barrett's esophagus and HGD without apparent cancer, frequent endoscopic surveillance with biopsies, rather than esophagectomy, is a valid and safe follow-up strategy for most patients with HGD without cancer, providing that 1 year of intensive endoscopic searching fails to detect cancer. Although management must be individualized, surgical resection of the esophagus should be reserved for those patients in whom cancer has been documented by biopsy.

Acknowledgements

The authors thank Jean Karpf, Gabe Levine, Shannon Reid, and Lawrence Brand.

References (19)

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    Citation Excerpt :

    The use of HGD as a surrogate marker for the risk of cancer developing from adenomas seems to be established, based on the concept of the adenoma-carcinoma sequence,25 although it is not fully known how long HGD persists before it develops into carcinoma, or to what extent this is related to other factors. There is better evidence for an increased risk of cancer development from HGD in the upper gastrointestinal tract.26–28 However, 2 recent meta-analyses that analyzed the risk of recurrence in relation to histologic parameters in the colon found that HGD had a higher risk of advanced neoplasia at follow-up than other histologic parameters, such as villous histology.18,29

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*

Address requests for reprints to: Thomas G. Schnell, M.D., Department of Veterans Affairs, Edward Hines, Jr., Hospital, Building No. 1, Room B321 (151B3), Hines, Illinois 60141. Fax: (708) 865-2048.

**

This work was funded entirely by the Department of Veteran's Affairs.

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