Barrett's cancer: indications, extent, and results of surgical resection

In the Western world, the prevalence of Barrett's carcinoma, i.e., adenocarcinoma of the distal esophagus arising from specialized columnar epithelial metaplasia, has risen dramatically in the past two decades. High-grade dysplasia in the columnar epithelium has been identified as the precursor of malignant carcinoma. Whether an esophagectomy should be performed in patients with high-grade dysplasia remains controversial. Surgical resection is the mainstay of therapy in patients with invasive adenocarcinoma who are fit for surgery. Complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of any surgical approach to adenocarcinoma of the distal esophagus. In patients with tumors located in the distal esophagus, this can be achieved by a radical transhiatal esophagectomy and proximal gastric resection with en bloc removal of the lymphatic drainage in the lower posterior mediastinum and along the celiac axis. Early adenocarcinoma can be cured by this approach. The value of multimodality therapy in patients with advanced tumors needs to be confirmed in well-designed randomized prospective trials.