surgical management of patients with HGD
HGD is defined as the detection in the Barrett’s epithelium of epithelial abnormalities that could equally be described as carcinoma in situ (markedly enlarged nuclei at the surface, pronounced pleomorphism and focal loss of nuclear polarity). Many large surgical series document that following esophageal resection, between 20% and 40% of patients with Barrett’s esophagus who have severe dysplasia will be found to actually have invasive carcinoma in the specimen . Although this does not imply that the majority of the patients will have invasive carcinoma, the inability to reliably distinguish the two groups preoperatively means that every patient with HGD should be thought of as having a probable carcinoma. In addition, the likelihood of developing cancer in the first 3 to 5 years once severe dysplasia has been identified is 25% to 50%. This increases to 80% risk of adenocarcinoma development in 8 years. Therefore the finding of HGD is an extremely strong indication for surgical resection. Although there are recommendations for less invasive therapy modalities, as ablation (photodynamic therapy, cryotherapy, radiofrequency [RF] ablation) and endoscopic mucosal resection, the most definitive treatment is esophagectomy. The latter is challenged with increased morbidity and mortality rates. Recently minimally invasive approaches as vagal sparing esophagectomy have gained popularity for treatment of HGD to decrease the rates of morbidity and mortality associated with resection.