Surgery versus radical endotherapies for early cancer and high grade dysplasia in Barrett's oesophagus.
BACKGROUND
Barrett's oesophagus is one of the most common premalignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little in the last 30 years. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late stage premalignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: i.e. conventional open surgery or endotherapy (techniques involving endoscopy).


OBJECTIVE
We used data from randomised controlled trials to examine the effectiveness of endotherapies compared with surgery, in people with Barrett's Oesophagus; those with early neoplasias (defined as high grade dysplasia (HGD), and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)).


METHODS
We used the Cochrane highly sensitive search strategy to identify randomized trials in MEDLINE, EMBASE, CENTRAL, ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN and LILACS, in July and August 2008.


METHODS
Types of studies: randomised controlled trials comparing endotherapies with surgery in the treatment of high grade dysplasia (HGD), or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately.


METHODS
patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus.Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent.


METHODS
Reports of studies which meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9.


RESULTS
We did not identify any studies which met the inclusion criteria.


CONCLUSIONS
This Cochrane review has indicated that there are no randomised control trials to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites; standardising histopathology in all centres; assessing which patients are fit or unfit for surgery; and making sure there are relevant outcomes for the study i.e. no progression of high grade dysplasia or long term survival i.e. over five years.
Gastroenterology, Portsmouth Hospitals Trust, Queen Alexandra Hospital, Spitalfield Road, Cosham, Hampshire, UK, PO6 3LY.
Susi
S
Green
Ashref
A
Tawil
Hugh
H
Barr
Cathy
C
Bennett
Pradeep
P
Bhandari
John
J
Decaestecker
Krish
K
Ragunath
Rajvinder
R
Singh
Janusz
J
Jankowski
D001471:Barrett Esophagus / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D004945:Esophagoscopy / Q000379:methods*; D006801:Humans; D011230:Precancerous Conditions / Q000473:pathology / Q000601:surgery*