Barrett 食管

尽管已证实 Barrett 食管与癌症的风险呈正相关，但许多（即便不是大多数）癌症患者没有典型或非典型的胃食管反流症状。2008 年 LOTUS 试验表明，药物治疗或抗反流手术治疗均可改善 Barrett 食管患者的症状，不过手术疗法能更有效地减少胃酸暴露。[60]Attwood SE, Lundell L, Hatlebakk JG, et al. Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience. J Gastrointest Surg. 2008;12:1646-1654.http://www.ncbi.nlm.nih.gov/pubmed/18709511?tool=bestpractice.com关于治疗时长，没有可靠的数据。大多数医生会让患者无限期地服用质子泵抑制剂，但是关于这种做法，没有数据支持，也没有数据反对。

尚未证实服用质子泵抑制剂能否阻止或延缓 Barrett 食管向癌症的进展。因此患者需要内镜监测。尽管尚未确定合适的监测周期，但多数权威机构推荐每两年进行一次内镜检查。

内镜下射频消融是消除无异型增生性 Barrett 化生的有效方法。[61]Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett's esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2013;11:1245-1255.http://www.cghjournal.org/article/S1542-3565(13)00603-4/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/23644385?tool=bestpractice.com尽管有高质量的证据表明超过 90% 的病例可实现完全消融，但关于这些患者食管腺癌风险降低的数据有限。[62]Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett's esophagus: initial results and lessons learned. Surg Endosc. 2009;23:2175-2180.http://www.ncbi.nlm.nih.gov/pubmed/19263139?tool=bestpractice.com[63]Wani S, Puli SR, Shaheen NJ, et al. Esophageal adenocarcinoma in Barrett's esophagus after endoscopic ablative therapy: a meta-analysis and systematic review. Am J Gastroenterol. 2009;104:502-513.http://www.ncbi.nlm.nih.gov/pubmed/19174812?tool=bestpractice.com

由于无异型增生性 Barrett 食管进展为异型增生和腺癌的风险低，指南不推荐常规使用内镜治疗（例如，射频消融 [RFA]）来根除该疾病。[1]Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63:7-42.http://gut.bmj.com/content/63/1/7.longhttp://www.ncbi.nlm.nih.gov/pubmed/24165758?tool=bestpractice.com[34]Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2017;49:191-198.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-122140http://www.ncbi.nlm.nih.gov/pubmed/28122386?tool=bestpractice.com[35]Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016;111:30-50;quiz 51.https://www.nature.com/ajg/journal/v111/n1/full/ajg2015322a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/26526079?tool=bestpractice.com

然而，如果将消融视为非异型增生性 Barrett 食管的辅助治疗，则必须采用基于风险的方法来选择具有较高风险的候选患者：50 岁以上的白人男性，有食管腺癌家族史，以及 Barrett 食管段较长。[1]Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63:7-42.http://gut.bmj.com/content/63/1/7.longhttp://www.ncbi.nlm.nih.gov/pubmed/24165758?tool=bestpractice.com[34]Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2017;49:191-198.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-122140http://www.ncbi.nlm.nih.gov/pubmed/28122386?tool=bestpractice.com[35]Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016;111:30-50;quiz 51.https://www.nature.com/ajg/journal/v111/n1/full/ajg2015322a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/26526079?tool=bestpractice.com

如果对质子泵抑制剂反应不良或者患者不愿继续服用该药，可考虑行抗反流手术。2008 年 LOTUS 试验表明，药物治疗或抗反流手术治疗均可改善 Barrett 食管患者的症状，不过手术疗法能更有效地减少胃酸暴露。[60]Attwood SE, Lundell L, Hatlebakk JG, et al. Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience. J Gastrointest Surg. 2008;12:1646-1654.http://www.ncbi.nlm.nih.gov/pubmed/18709511?tool=bestpractice.com

必须足够适合行手术治疗。

已经表明，有经验的外科医生和大容量的转诊中心能使患者的结局更好。

腹腔镜或开腹、Nissen 或 Toupet 胃底折叠术可与试验性内镜消融技术联合使用。

抗反流手术似乎可减少或防止异型增生发生。[64]Rees JR, Lao-Sirieix P, Wong A, et al. Treatment for Barrett's oesophagus. Cochrane Database Syst Rev. 2010;(1):CD004060.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004060.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/20091557?tool=bestpractice.com

抗反流术后是否需要继续使用质子泵抑制剂治疗仍是一个未解决的问题。没有数据支持或反对这种做法。

应将射频消融作为 Barrett 食管扁平（非结节性）轻度异型增生的标准治疗方法。[1]Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63:7-42.http://gut.bmj.com/content/63/1/7.longhttp://www.ncbi.nlm.nih.gov/pubmed/24165758?tool=bestpractice.com[34]Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2017;49:191-198.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-122140http://www.ncbi.nlm.nih.gov/pubmed/28122386?tool=bestpractice.com[35]Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016;111:30-50;quiz 51.https://www.nature.com/ajg/journal/v111/n1/full/ajg2015322a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/26526079?tool=bestpractice.com

对于轻度异型增生结节性病变，应采用内镜下黏膜切除术治疗。建议随后使用射频消融消除所有剩余的 Barrett 化生区域。[1]Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63:7-42.http://gut.bmj.com/content/63/1/7.longhttp://www.ncbi.nlm.nih.gov/pubmed/24165758?tool=bestpractice.com[34]Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett's esophagus: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2017;49:191-198.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0042-122140http://www.ncbi.nlm.nih.gov/pubmed/28122386?tool=bestpractice.com[35]Shaheen NJ, Falk GW, Iyer PG, et al. ACG Clinical Guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016;111:30-50;quiz 51.https://www.nature.com/ajg/journal/v111/n1/full/ajg2015322a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/26526079?tool=bestpractice.com

应考虑将射频消融作为 Barrett 食管扁平（非结节性）高度异型增生的标准治疗方法。[52]National Institute for Health and Care Excellence. Barrett's oesophagus: ablative therapy. August 2010. http://guidance.nice.org.uk (last accessed 18 July 2017).https://www.nice.org.uk/guidance/cg106一项大型多中心随机试验已证实，该技术可消除高度异型增生，并降低食管腺癌的风险。[57]Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett's esophagus with dysplasia. N Engl J Med. 2009;360:2277-2288.http://www.nejm.org/doi/full/10.1056/NEJMoa0808145#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/19474425?tool=bestpractice.com

对于存在高度异型增生的结节性病变，应进行内镜下黏膜切除术。随后采用射频消融根除所有剩余的 Barrett 化生区域，这可以减少高度异型增生向癌症的进展。[52]National Institute for Health and Care Excellence. Barrett's oesophagus: ablative therapy. August 2010. http://guidance.nice.org.uk (last accessed 18 July 2017).https://www.nice.org.uk/guidance/cg106

针对经选择患者组全部患者的治疗推荐

如果有症状，使用这些药物可改善症状（但可能不会改善反流和非典型症状）。

尚未证实使用质子泵抑制剂能否阻止或延缓 Barrett 食管向癌症的进展。

食管切除术是一种确定性治疗选择，通过该方法可发现任何隐匿性恶性肿瘤。[58]Rice TW, Sontag SJ. Debate: esophagectomy is the treatment of choice for high grade dysplasia in Barrett's esophagus. Am J Gastroenterol. 2006;101:2177-2184.http://www.ncbi.nlm.nih.gov/pubmed/17032178?tool=bestpractice.com在活检提示高度异型增生的患者中，大约 20% 至 40% 的患者实际上存在隐匿性早期腺癌。[1]Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63:7-42.http://gut.bmj.com/content/63/1/7.longhttp://www.ncbi.nlm.nih.gov/pubmed/24165758?tool=bestpractice.com[55]Tseng EE, Wu TT, Yeo CJ, et al. Barrett's esophagus with high grade dysplasia: surgical results and long-term outcome - an update. J Gastrointest Surg. 2003;7:164-171.http://www.ncbi.nlm.nih.gov/pubmed/12600440?tool=bestpractice.com