[Complications of Barrett's esophagus: indications for esophageal resection with special reference to high-grade dysplasia].

BACKGROUND: Columnar lined oesophagus (Barrett's oesophagus) can sometimes be associated with complications such as stricture, ulcer and dysplasia. In some selected cases there is an indication for oesophageal resection. METHODS: From 1983 to 1997, 12 patients underwent oesophagectomy for "complicated" Barrett's oesophagus. All patients had gastroesophageal reflux and Barrett metaplasia for many years. Ten of them were symptomatic, and pH-manometric alterations as well as alterations were noted at biliary scintigraphy. Ten patients had intestinal metaplasia. Two patients had previous antireflux operations. Four had a long (3-5 cm) and undilatable stricture. One was affected by a perforating ulcer. One patient had an indefinite grade dysplasia but endosonography revealed high suspicion of cancer. Six patients had a high-grade dysplasia. Operative technique consisted of a transhiatal oesophagectomy in nine cases and a laparotomic and right thoracotomic oesophagectomy (Ivor-Lewis) in two. RESULTS: There was no 30-day mortality; three post operative complications were observed. One of the four patients suffering from stricture died four years after intervention due to non-related causes; the other three are still living and regularly feed per os after 12, 9 and 7 years. The patient with ulcer is still living after 6 years and regularly feeding per os. The patient suffering from an indefinite grade dysplasia had an adenocarcinoma (stage IIa) on the operative specimen. The patient is still living after 2 years. Three patients operated for high-grade dysplasia had an adenocarcinoma on the specimen. Two patients (stage I) are living after 3 and 5 years. One patient (stage IIa) died after 19 months with recurrence. CONCLUSIONS: In case of non neoplastic "complicated" Barrett's oesophagus the indication for the oesophageal resection can be considered as the extreme useful therapy only after an accurate selection of patients. Especially in case of high-grade dysplasia, the great incidence of unexpected adenocarcinoma indicates oesophagectomy for patients who are suitable for surgery.