High-grade dysplasia in Barrett's oesophagus. The case against oesophageal resection.

Abstract

Treatment of oesophageal high-grade dysplasia is one of the great conundrums facing oesophageal surgeons. Both authors allude to the uncertainty of the natural history of high-grade dysplasia, especially the rate of progression to invasive cancer and furthermore to the variation in reported incidence of carcinoma in post oesophagectomy resections for high-grade dysplasia. Professor Barr adopts the minimalist approach – favouring local ablative therapy (such as photodynamic therapy or endoscopic mucosal resection [EMR]) and endoscopic surveillance – postulating these inconveniences are better than death or life-long morbidity following oesophagectomy for a pathologically variable disease. Mr Maynard quotes very impressive mortality following transhiatal oesophagectomy and rightly alludes to the fact that increasing depth of mucosal neoplasia equates to higher nodal disease with consequent reduction in survival from higher tumour stage. What is the correct approach? Probably the answer will lie in increased use of EMR: this will enable better pretreatment staging and identification of patients with multifocal disease. Those whom are fit, have multifocal long-segment disease and with extending depths of neoplasia on EMR histology might fare best with surgical resection. The unfit with short-segment, superficial disease may suffice with endoscopic therapy/surveillance. Tom Dehn