Barrett's Esophagus: A Surgical Disease?

Lord, Reginald V. N.; Bowrey, David J.; Blom, Dennis; Johnson, David
November 2000
American Journal of Gastroenterology;Nov2000, Vol. 95 Issue 11, p3302
Academic Journal
Csendes et al. randomized 164 patients with chronic GERD to treatment with either open Nissen fundoplication (n = 76) or open posterior gastropexy and calibration of the cardia (Hill-Larrain operation, n = 88). The latter operation involves plicating the gastroesophageal junction and fixing it to the median arcuate ligament. Most (61.5%) of the patients had Barrett's intestinal metaplasia, with long segment (≥3 cm) Barrett's present in every case. Patients with Barrett's esophagus complicated by dysplasia, ulcer, stricture, or short esophagus were excluded. The follow-up protocol involved multiple clinical, endoscopic, and manometric examinations, with quantification of gastroesophageal reflux using radionuclide scintigraphy before 1990 and 24 h pH-monitoring for the later years of the study. Recurrence was defined by the presence of recurrent symptoms or endoscopic esophagitis. There was 95% follow-up at a mean of 85 months. The recurrence rate for both operations was similar, although the rate was a significantly different between patients with and without Barrett's esophagus. The recurrence rate at 5 yr for patients without Barrett's esophagus was 15% for fundoplication and 19% for cardiopexy, whereas the corresponding figures for patients with Barrett's patients were 45% and 57%, respectively. At 10 yr, there was a recurrence rate of 23-25% for those without Barrett's esophagus, compared to 80-83% for the Barrett's esophagus group. Seventy-seven percent of those without Barrett's esophagus were Visick grade I and II at 10-yr follow-up. Low-grade dysplasia developed in 13% of the Barrett's esophagus patients. Eventual failure of surgical therapy was associated with progressive loss of the lower esophageal sphincter pressure after operation. Patti et al. reviewed 535 patients with an objective diagnosis of GERD who were referred to the University of California, San Francisco (UCSF). Barrett's intestinal metaplasia was present in 72 (13%) of the GERD group. The biopsy protocol information given suggests that the Barrett's group contained only those patients with macroscopically visible columnar epithelium. A radiographically detected hiatal hernia was present in 39% of the patients with no esophagitis, in 64% of those with esophagitis, and in 80% of the patients with Barrett's esophagus. Manometric features of lower esophageal sphincter incompetence, esophageal body hypomotility, and abnormal acid reflux worsened with increasing degrees of mucosal injury, and were worst in the Barrett's group. Laparoscopic fundoplication was performed in 38 patients with Barrett's esophagus. Half of the patients received a circumferential (Nissen) fundoplication and half were treated by partial fundoplication. Comparison of preoperative symptom scores (with all patients treated by proton pump inhibitor medication) and postoperative scores (at a mean 23 ± 14 months follow-up) showed that fundoplication provided excellent symptom relief (P < 0.0001 for all symptoms). There was no change in either the length or the histopathology of the Barrett's epithelium. Patti et al. also reviewed their results for 11 patients with a maximum preoperative diagnosis of high-grade dysplasia who underwent esophagectomy. The esophagectomy specimen contained adenocarcinoma in four patients and high-grade dysplasia in the remaining patients. Three of the cancer patients had disease that was not limited to the mucosa and died within 16 months of operation.


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