Multimodal surgical treatment of patients with columnar epithelial metaplasia of the esophageal mucosa: Summary of the doctoral thesis in medical sciences: 321.13 - Surgery

Abstract

The actuality of the subject: Columnar epithelial metaplasia of the esophageal mucosa, formerly known as Barrett's esophagus (BE) or metaplased columnar esophagus (MCE), is currently a major concern problem for medical practice and science, primarily due to its evolutionary correlation with chronic gastroesophageal reflux disease (GERD), which, due to its high and continuously growing incidence in Western European countries, is considered a disease of the XXIst century. Secondly, no less important, in this respect is the potential for malignancy of the MCE with the association of dysplasia and the development of esophageal adenocarcinoma (AC) [1]. The widespread introduction of endoscopic diagnostic methods into daily practice demonstrates that MCE is a relatively common finding, with an incidence of up to 2% of all esophagoscopies and up to 10-20% of the endoscopies performed in patients with symptoms of gastroesophageal reflux disease (GERD) [2,3]. The clinical importance of MCE is determined by the predisposition to evolution complications (ulceration, hemorrhage or stricture) and especially due to the potential for malignancy, intensively studied recently. The risk of developing AC in patients with intestinal MCE has been estimated to be 30–40 times higher than in the general population [4]. The increase in the incidence of AC, especially observed in Western Europe, North America and Japan, has caused a series of controversies over the past 4 decades among surgeons, gastroenterologists and pathologists regarding Barrett's esophageal metaplasia. If, initially, the debates focused on the congenital or acquired origin of this condition, then the controversy focused on the origin of the cylindrical epithelium in the eso-gastric junction (EGJ), as well as on its histopathological aspects. An issue that has not yet been resolved among the profile specialists is referred to the definition and diagnosis of MCE. The basic criteria for its diagnosis have evolved over time, and if BE was initially considered an eponym for the syndrome that characterizes the replacement of stratified squamous epithelium with columnar epithelium, being diagnosed if the squamous-columnar junction (SCJ) was 3 cm above the EGJ, by endoscopic or histopathological examination, currently, in terms of definition, for reasons of oncological vigilance the need to consider Barrett mucosa as only MCE of specialized intestinal type [5-8] is more and more emphasized, and, in terms of diagnosis, the problem of the necessity in population screening programs, as well as the necessity in monitorization schemes regarding the evolution of MCE, are becoming increasingly important. Surgeons have reported a favorable response of columnar metaplastic lesions (as well as for AC prophylaxis) to the surgical treatment of reflux, ablative surgical treatment of metaplasia, compared to continuous antacid therapy, but this still remains a controversial issue [9 - 11]. Antisecretory medication appears to be effective in eliminating GERD symptoms, but its long-term application may cause adverse reactions, a negative therapeutic cost/efficacy balance, and the potential for reversibility of MCE in normal anatomical-physiological conditions/neoplastic progression is discussed. [...]