Esophagectomy for Barrett's esophagus: indications, techniques, and outcome.

Barrett's esophagus describes metaplastic changes from squamous mucosa to specialized columnar epithelium that can progress from low-grade dysplasia to high-grade dysplasia and even invasive carcinoma. The treatment of Barrett's esophagus with low-grade dysplasia or Barrett's adenocarcinoma is relatively standardized; however, controversy remains regarding appropriate therapy for Barrett's esophagus with high-grade dysplasia. Treatment recommendations for high-grade dysplasia vary widely, from periodic endoscopic surveillance to endoscopic ablative therapies and esophagectomy. Selected studies have shown that a relatively high percentage (41% to 47%) of patients with high-grade dysplasia have occult carcinoma. In these patients, surgery is indicated, as esophagectomy can be curative for early stage adenocarcinoma in Barrett's esophagus. A major criticism of esophagectomy is the significant morbidity and mortality. Minimally invasive esophagectomy was developed in an effort to reduce the morbidity associated with open esophagectomy. In minimally invasive esophagectomy, the abdominal laparotomy is replaced with laparoscopy, and the conventional right thoracotomy is replaced with thoracoscopy to reduce the operative trauma. In experienced centers, minimally invasive esophagectomy is now an attractive alternative for the treatment of Barrett's esophagus with high-grade dysplasia.