Surgical management of Barrett's esophagus

Barrett's esophagus is a premalignant metaplastic change in the lining of the distal esophagus. It represents a peculiar form of healing which can occur at any time in patients with reflux esophagitis. Ninety percent of patients with Barrett's esophagus have a mechanically defective lower esophageal sphincter and 93% have abnormal esophageal acid exposure on 24 hour esophageal pH monitoring. Barrett's esophagus should be considered in all patients undergoing endoscopy for symptoms of reflux disease and is confirmed when any biopsy shows the presence of specialized intestinal metaplasia, irrespective of the macroscopic appearances of the distal esophagus. An anti-reflux procedure is indicated for patients with Barrett's esophagus since it is highly effective in controlling reflux symptoms, healing the associated esophagitis, prevents repetitive injury of the Barrett's epithelium, and is more effective than medical therapy in the long term. Annual endoscopic surveillance with multiple biopsy sampling of the esophageal mucosa is indicated after the antireflux repair. Identification of high grade dysplasia heralds the development of invasive cancer and offers the surgeon an opportunity to intervene. Despite extensive endoscopic sampling of the esophageal mucosa the differentiation between high grade dysplasia and invasive adenocarcinoma is unreliable. Esophagectomy remains the treatment of choice for patients with high grade dysplasia. Barrett's adenocarcinoma can be cured by en bloc esophagectomy in selected patients with early disease.