Complications of Barretts Esophagus

Reflux is thought to be the primary impetus for the development of Barrett's esophagus. Longsegment Barrett's esophagus is identified in up to 1% of individuals without GERD and in 5-10% of patients with GERD symptoms.25-27 The incidence seems to increase with advancing age, making it an important concern in the elderly. Barrett's esophagus is an indication for esophagectomy in two classes of individuals. First, in rare circumstances a Barrett's ulcer can develop, which burrows deeply like a gastric ulcer instead of spreading superficially like ulcerations in the squamous esophageal mucosa. Although such ulcers can be controlled with intensive medical therapy, they sometimes extend transmurally and invade other structures, creating a life-threatening situation. In the presence of a deep chronic Barrett's ulcer, esophagectomy should be strongly considered.

The other situation in which Barrett's esophagus is an indication for surgery is when highgrade dysplasia develops. The likelihood of developing high-grade dysplasia is about 1 in every 200 patient years, making the overall risk relatively small.28 However, when high-grade dysplasia is identified on endoscopic biopsy, there is a 40-50% risk of invasive adenocarci-noma in the esophagus.29 Moreover, in patients with high-grade dysplasia who are followed in an endoscopic surveillance program, the risk of developing an invasive cancer is about 1 in every 200 patient years.30,31 Currently the standard therapy for Barrett's esophagus with documented high-grade dysplasia is esophagectomy. However, recent information suggests that the increasing frequency with which Barrett's esophagus is being diagnosed has resulted in a decreasing incidence of high-grade dysplasia.32 This fact, combined with the development of newer treatment modalities for eradicating high-grade dysplasia, may lessen the need for esophagectomy.

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