Impact of Laparoscopic Nissen Fundoplication on Non-complicated Barrett��s Esophagus

Background/Aim:

Laparoscopic fundoplication can alter the natural course of Barrett’s esophagus (BE). This study was undertaken to assess this role in patients with non-complicated BE.

Materials and Methods:

From October 2004 to October 2009, 43 patients with BE (32 men and 11 women) underwent laparoscopic Nissen fundoplication surgery in the Department of Surgery at Minia University Hospital. The median age of these patients was 46 years (range: 22–68 years). Patients with high-grade dysplasia, invasive cancer, or previous antireflux surgery were excluded. All 43 patients had gastroesophageal reflux symptoms. Heartburn was present in all patients, regurgitation in 41 (95.3%), dysphagia in 8 (18.6%), retrosternal pain in 30 (69.8%), upper gastrointestinal hemorrhage in 6 (13.9%), and respiratory symptoms in 19 (44.2%). Nissen fundoplication was performed in all patients. Thirty-four patients (79.1%) had concomitant hiatal hernia and nine patients (20.9%) had low-grade dysplasia.

Results:

The median follow-up period was 25.6 months. There was significant improvement of symptoms after surgery (P<0.05). Eight (18.6%) of those with short-segment BE had total regression and four (9.3%) of those with long-segment BE had a decrease in total length. Among the nine patients with preoperative low-grade dysplasia, dysplasia disappeared in seven, remained unchanged in one, and progressed to in situ adenocarcinoma in one patient.

Conclusions:

laparoscopic fundoplication succeeded in controlling symptoms but had unpredictable effect on dysplasia and regression of BE. Laparoscopic fundoplication does not eliminate the risk of developing esophageal adenocarcinoma and therefore, endoscopic follow-up should be continued in these patients.     

Efficacy and one year follow up of argon plasma coagulation therapy for ablation of Barrett's oesophagus: factors determining persistence and recurrence of Barrett's epithelium

INTRODUCTION: Barrett's epithelium (BE) has malignant potential. Neither acid suppression nor antireflux surgery produce consistent or complete regression of the metaplastic epithelium. Endoscopic thermoablation with argon plasma coagulation (APC) offers a different approach but factors influencing its outcome have not been systematically examined. AIM: To assess the efficacy of APC and factors influencing initial and one year outcome. METHODS: Fifty patients, mean age 61.4 years, mean BE length 5.9 cm (range 3-19), underwent APC therapy at four weekly intervals while receiving proton pump inhibitor (PPI) therapy. BE margins were marked by India ink tattooing and extent was documented by grid drawings, photography, and 2 cm interval quadrantic jumbo biopsies. Twenty four hour ambulatory oesophageal pH studies were done while on PPIs before and after APC therapy, and Bilitec bilirubin monitoring after APC completion. RESULTS: A total of 68% of patients achieved >90% BE ablation after a median of four APC sessions. Persistent BE (>10% original BE area) was associated with longer initial BE length despite more APC sessions. Persistent acid and bile reflux on PPIs, although commoner in this group, were not significantly different from those successfully ablated. Fifteen of 34 patients (44%) with successful macroscopic clearance had buried glands, present in 8.3% of a total of 338 biopsies. At the one year follow up, only 32% of those with initial successful ablation showed no recurrence. BE recurred or increased in most with mean segment length increases of 1.1 cm and 1.6 cm, respectively, in patients with previous full ablation and those with persistent BE. The presence of buried glands did not predict BE recurrence. Patients who reduced their PPI dose had significantly greater BE recurrence. CONCLUSIONS: APC is most effective for shorter segment BE ablation but "buried" glands do occur. Recurrence of BE is common at one year, especially in those with initial persistent and/or long segment BE and those who reduce their PPI dose.     

Randomized trials in the treatment of Barrett''s esophagus

Treatment for Barrett's esophagus (BE) has consisted of medical treatment (acid suppression medications), surgery (fundoplication) and endoscopic ablative techniques (photodynamic therapy, argon plasma coagulation and multipolar electrocoagulation). Despite the large number of clinical trials of the efficacy of different therapeutic modalities, there is a paucity of published randomized controlled trials. The aim of this review is to evaluate the published randomized therapeutic trials in patients with BE. A comprehensive MEDLINE search was performed to review randomized clinical trials of different therapeutic modalities in BE. Only eight randomized studies have been published. The eight randomized studies reviewed include: two trials that evaluated medical and surgical therapy; two placebo controlled trials for photodynamic therapy (PDT); one placebo controlled trial comparing argon plasma coagulation (APC) versus surveillance; two trials comparing PDT versus APC; and one trial comparing APC versus multipolar electrocoagulation (MPEC). All the studies are prospective, however only one study is double-blinded. Each study has a small sample size, uses a different population of BE patients (dysplasia versus no dysplasia, short segment BE versus long segment BE), has different defined endpoints (endoscopic ablation of BE, number of treatments required for endoscopic ablation of BE, and elimination of high grade dysplasia) and the methodology for the treatment modalities is different among the studies. Though the data to support the use of endoscopic ablative techniques in the treatment of BE are promising, more rigorous double-blind and larger, well designed randomized studies are required to draw any definitive conclusions.     

Nissen fundoplication in infants and children: a long-term clinical study

BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication for gastroesophageal reflux disease were retrospectively evaluated to assess the success and complications of this operation. METHODOLOGY: Twenty-six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow-up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The median follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and re-stricture. Both refused a second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.     

Long-term follow-up after complete ablation of Barrett＇s esophagus with argon plasma coagulation

AIM: To report the long-term outcome of patients after complete ablation of non-neoplastic Barrett's esophagus (BE) with respect to BE relapse and development of intraepithelial neoplasia or esophageal adenocarcinoma. METHODS: In 70 patients with historically proven non neoplastic BE, complete BE ablation was achieved by argon plasma coagulation (APC) and high-dose proton pump inhibitor therapy (120 mg omeprazole daily). Sixty-six patients (94.4%) underwent further surveillance endoscopy. At each surveillance endoscopy four-quadrant biopsies were taken from the neo-squamous epithelium at 2 cm intervals depending on the pre-treatment length of BE mucosa beginning at the neo-Z-line, and from any endoscopically suspicious lesion. RESULTS: The median follow-up of 66 patients was 51 mo (range 9-85 mo) giving a total of 280.5 patient years. A mean of 6 biopsies were taken during surveillance endoscopies. In 13 patients (19.7%) tongues or islands suspicious for BE were found during endoscopy. In 8 of these patients (12.1%) non-neoplastic BE relapse was confirmed histologically giving a histological relapse rate of 3% per year. In none of the patients, intraepithelial neoplasia nor an esophageal adenocarcinoma was detected. Logistic regression analysis identified endoscopic detection of islands or tongues as the only positive predictor of BE relapse (P= 0.0004). CONCLUSION: The long-term relapse rate of non neoplastic BE following complete ablation with high-power APC is low (3% per year).     

Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM:To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication(TIF).METHODS:TIF is a new endoscopic approach for treating gastroesophageal reflux disease(GERD).In cases of TIF failure,subsequent laparoscopic fundoplication may be required.All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication.Primary outcome measures included operative time,blood loss,length of hospital stay and complications encountered.RESULTS:A total of 5 patients underwent revisional laparoscopic Nissen fundoplication(LNF)or gastrojejunostomy for recurrent GERD at a median interval of 24mo(range:16-34 mo)after TIF.Patients had recurrent reflux symptoms at an average of 1 mo following TIF(range:1-9 mo).Average operative time for revisionalsurgical intervention was 127 min(range:65-240 min)and all surgeries were performed with a minimal blood loss(<50 m L).There were no cases of gastric or esophageal perforation.Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously.Median length of hospitalization was 2 d(range:1-3 d).All patients had resolution of symptoms at the last follow up.CONCLUSION:LNF is a feasible and safe option in a patient who has persistent GERD after a TIF.Previous TIF did not result in additional operative morbidity.     

内镜APC治疗短段Barrett食管近期临床观察

Barrett食管（BE）为公认的食管癌前病变,有发展成为食管腺癌的风险。内镜治疗是目前临床上BE的主要治疗手段。目的：探讨内镜氩离子凝固术（APC）治疗短段BE的近期疗效和安全性。方法：选取经内镜和病理检查确诊,于2010年6月一2011年12月在嵊泗县人民医院接受内镜30WAPC治疗辅以雷贝拉唑口服维持的短段BE患者,对其病史资料进行回顾性分析。结果：共12例短段BE患者纳入研究,11例完成内镜随访。9例患者首次APC治疗即完全清除病灶,2例患者接受2次APC治疗,按意向治疗分析总有效率为91．7％,无严重并发症发生。病灶完全清除后6个月、12个月内镜随访均未见复发。结论：内镜APC联合质子泵抑制剂维持治疗对清除短段BE近期疗效显著、安全,易于在基层医院开展。     

Ablation of nonneoplastic Barrett's mucosa using argon plasma coagulation with concomitant esomeprazole therapy (APBANEX): a prospective multicenter evaluation

BACKGROUND: Complete reversal of Barrett's epithelium (BE) achieved by treatment with argon plasma coagulation (APC) is variable. The aim of this prospective study was to evaluate the effectiveness of high-power APC in a multicenter trial. METHODS: In seven study centers, 60 patients (mean age 57, range 27-77) with nonneoplastic BE (length 1-8 cm) were recruited for treatment with high-power APC (90 W) in combination with esomeprazole 80 mg/day. Video endoscopy, chromoendoscopy, and four-quadrant biopsies (4QB) were carried out during baseline endoscopy and regular intervals. The effect of ablation was classified as complete remission (CR), partial remission, or minor response. RESULTS: Fifty-one of the 60 patients completed ablation therapy. Three patients were lost to follow-up (FU). After a mean of 2.6 APC sessions (range 1-5) and a mean FU of 14 months (range 12-32), CR was achieved in 37 of 48 patients (77%). Major complications occurred in five of 51 patients (9.8%). CONCLUSIONS: Complete ablation of BE can be achieved in a high percentage of patients even in a multicenter design using high-power APC. However, APC has a relevant morbidity. Therefore, ablation of nonneoplastic BE cannot be recommended generally because incidence of cancer in BE is low.     

Safety and efficacy of endoscopic spray cryotherapy for Barrett's dysplasia: results of the National Cryospray Registry

Retrospective series have shown the efficacy of endoscopic spray cryotherapy in eradicating high‐grade dysplasia (HGD) in Barrett's esophagus (BE); however, prospective data are lacking, and efficacy for low‐grade dysplasia (LGD) is unclear. The aim of this study was to assess the efficacy and safety of spray cryotherapy in patients with LGD or HGD. A multicenter, prospective open‐label registry enrolled patients with dysplastic BE. Spray cryotherapy was performed every 2–3 months until there was no endoscopic evidence of BE and no histological evidence of dysplasia, followed by surveillance endoscopies up to 2 years. Primary outcome measures were complete eradication of dysplasia (CE‐D) and complete eradication of all intestinal metaplasia (CE‐IM). Ninety‐six subjects with Barrett's dysplasia (67% HGD; 65% long‐segment BE; mean length 4.5 cm) underwent 321 treatments (mean 3.3 per subject). Mean age was 67 years, 83% were male. Eighty patients (83%) completed treatment with follow‐up endoscopy (mean duration 21 months). In patients with LGD, rate of CE‐D was 91% (21/23) and rate of CE‐IM was 61% (14/23). In HGD, CE‐D rate was 81% (46/57) and CE‐IM was 65% (37/57). In patients with short‐segment BE (SSBE) with any dysplasia, CE‐D was achieved in 97% (30/31) and CE‐IM in 77% (24/31). There were no esophageal perforations or related deaths. One subject developed a stricture, which did not require dilation. One patient was hospitalized for bleeding in the setting of non‐steroidal anti‐inflammatory drug use. In the largest prospective cohort to date, data suggest endoscopic spray cryotherapy is a safe and effective modality for eradication of BE with LGD or HGD, particularly with SSBE.     

Effects of low-power argon plasma coagulation thermoablation of Barrett's epithelium on oesophageal motility

INTRODUCTION: Oesophageal dysmotility contributes to the pathogenesis of Barrett's epithelium (BE) allowing prolonged mucosal contact with injurious refluxate. Argon plasma coagulation (APC) is effective for BE ablation, but it is unknown whether the procedure affects oesophageal motility. AIM: To assess the effect of low power (30 W) APC therapy on oesophageal motility in patients with BE. METHODS: Thirty-three patients with at least 4 cm of BE underwent oesophageal manometry before and after APC ablation. All were on proton pump inhibitors. Oesophageal body peristaltic wave duration and amplitude, and lower oesophageal sphincter (LOS) pressure and length were compared before and after treatment. RESULTS: In a total of 28 men and five women, with a mean age of 63.4 years (range 39-79) and mean BE length 6.5 cm (range 4-19), macroscopic clearance was achieved in 28 patients. A small statistically significant (P<0.05) increase in peristaltic wave amplitude was seen after APC [mean (SD) mmHg before versus after: 30.4 (15.2) versus 36.2 (20.1) at 13.5 cm, 47.6 (27.1) versus 54.5 (26.8) at 8.5 cm, and 51.2 (35.3) versus 58 (34.4) at 3.5 cm above the LOS]. No changes in either peristaltic wave duration or LOS parameters [mean (SD) pressure 10.6 (5.6) versus 10.3 (4.3) mmHg; length 2.8 (1.3) versus 2.8 (1.0) cm] were observed. CONCLUSION: APC ablation of BE at a power setting of 30 W does not impair oesophageal motility.     

Visible endoscopic and histologic changes in the cardia, before and after complete Barrett's esophagus ablation

BACKGROUND: Adverse events associated with the thermal ablation of Barrett's esophagus (BE) include the generation of gastric mucosa buried beneath the neosquamous regrowth, and unrecognized development and growth of adenocarcinomas. No reports exist regarding the endoscopic appearance and histology of the cardia before and after BE ablation. The aim of our study was to assess the relative frequency of the occurrence of visible endoscopic and histologic changes in the cardia, before and after complete BE ablation. METHODS: A subset analysis of patients with uncomplicated BE, BE with dysplasia, or early carcinoma, who had been enrolled into one of 4 ongoing prospective studies of mucosal ablation, was examined. Eighty-two patients were identified who entered a BE ablation study, with 75 of these completing BE mucosal ablation. Cardia biopsy specimens were taken in all patients before ablation and serially after BE ablation. Cardia histology was graded by using the modified Sydney System for gastritis. RESULTS: Before ablation, cardia nodules were noted in 3, cardia intestinal metaplasia (IM) in 7 (8.5%), and none harbored cardia dysplasia. Postablation surveillance ranged from 3 to 75 months (mean 31.1 months [19.5]). Six subjects (8%) developed cardia nodules during surveillance; cardia IM was found in 21(28%), with 17 of these being a new finding (incidence of 25%). Cardia low-grade dysplasia incidence was 1.3% and high-grade dysplasia was 4% after BE ablation. CONCLUSIONS: The pathophysiology of the abnormal cardia histology and the endoscopic lesions (nodules) is unclear, but endoscopic surveillance of not only the neosquamous epithelium but also the cardia should be considered after ablation, especially in those high-grade dysplasia and early adenocarcinoma BE patients.     

Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett's esophagus: 1-year follow-up of 100 patients

OBJECTIVE: To assess the dose-response, safety, and efficacy of circumferential endoscopic ablation of Barrett's esophagus (BE) by using an endoscopic balloon-based ablation device (HALO360 System). DESIGN: This study was conducted in 2 serial phases (dosimetry phase and effectiveness phase) to evaluate a balloon-based ablation device that delivers a pre-set amount of energy density (J/cm2) to BE tissue. The dosimetry phase evaluated the dose-response and the safety of delivering 6 to 12 J/cm2. The effectiveness phase used 10 J/cm2 (delivered twice [x2]) for all patients, followed by EGD with biopsies at 1, 3, 6, and 12 months. A second ablation procedure was performed if BE was present at 1 or 3 months. Patients received esomeprazole 40 mg twice a day for 1 month after ablation, and 40 mg every day thereafter. Postablation symptoms were quantified by using a 14-day symptom diary (scale, 0-100). A complete response (CR) was defined as all biopsy specimens negative for BE at 12 months. SETTING: Eight U.S. centers, between September 2003 and September 2005. PATIENTS: Patients were 18 to 75 years of age, with a diagnosis of BE (without dysplasia), with histopathology reconfirmation of the diagnosis within 6 months of enrollment. RESULTS: In the dosimetry phase, 32 patients (29 men; mean age, 56.8 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 3. There were no dose-related serious adverse events, and the outcomes at 1 and 3 months permitted the selection of 10 J/cm2 (x2) for the subsequent effectiveness phase of the study. In the effectiveness phase, 70 patients (52 men, 18 women; mean age, 55.7 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 4. At 12 months (n = 69; mean, 1.5 sessions), a CR for BE was achieved in 70% of patients. There were no strictures and no buried glandular mucosa in either study phase (4306 biopsy fragments evaluated). CONCLUSIONS: Circumferential ablation of nondysplastic BE by using this balloon-based ablation device can be performed with no subsequent strictures or buried glands and with complete elimination of BE in 70% of patients at 1-year follow-up.     

A randomised controlled trial of ablation of Barrett's oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results

BACKGROUND: Many modalities have been used to ablate Barrett's oesophagus (BO). However, long term results and comparative effectiveness are unknown. AIMS: Our aim was to compare the long term efficacy of achieving complete reversal (endoscopic and histological) between multipolar electrocoagulation (MPEC) and argon plasma coagulation (APC) in BO patients and assess factors influencing successful ablation. METHODS: Patients with BO, 2-6 cm long, underwent 24 hour pH testing on proton pump inhibitor (PPI) therapy. Patients were then randomised by BO length to undergo ablation with MPEC or APC every 4-8 weeks until endoscopic reversal or maximal of six treatment sessions. RESULTS: Thirty five BO patients have been followed for at least two years following endoscopic ablation, 16 treated with MPEC and 19 with APC. There was complete reversal of BO in 24 patients (69%); 75% with MPEC and 63% with APC (p = 0.49). There was no difference in the number of sessions required in the two groups. There was no difference in age, pH results, BO length, PPI dose, or hiatal hernia size between patients with and without complete reversal. One patient developed an oesophageal stricture but there were no major complications such as bleeding or perforation. CONCLUSIONS: In BO patients treated with MPEC or APC in combination with acid suppression, at long term follow up, complete reversal of BO can be maintained in approximately 70% of patients, irrespective of the technique. There are no predictors associated with achieving complete reversal of BO. Continued surveillance is still indicated in the post ablative setting. As yet, these techniques are not ready for clinical application (other than for high grade dysplasia or early oesophageal adenocarcinoma) and cannot be offered outside the research arena.     

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND: There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM: To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS: There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION: Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.     

Endoscopic ablation of Barrett＇s esophagus using high power setting argon plasma coagulation： A prospective study

AIM: This prospective study evaluated the effectiveness of 90 W argon plasma coagulation (APC) for the ablation of Barrett's esophagus (BE) that is considered to be the main risk factor for the development of esophageal adenocarcinoma. METHODS: The results from 25 patients, observed at the First Department of General Surgery, University of Verona, Italy, from October 2000 to October 2003, who underwent APC for histologically proven BE were prospectively analyzed, RESULTS: The ablation treatment was completed in all the patients but one (96%). The mean number of APC sessions needed to complete ablation was 1.6 (total number: 40). The eradication was obtained in the majority of cases by one session only (60%), two sessions were required in 24% of the cases and three or more in 16%. About 43% of the sessions were complicated. Retrosternal pain (22.5%) and fever (17.5%) were the most frequent symptoms. Only one major complication occurred, it was an hemorrhage due to ulcer formation on the treated esophagus that required urgent endoscopic sclerosis and admission. The follow-up was accomplished in all the patients with a mean period of 26.3 mo and 20 patients (84%) with a follow-up period longer than 24 mo. Only one patient showed a relapse of metaplastic mucosa 12 mo after the completion of ablation. The patient was hence re-treated and now is free from recurrence 33 mo later. CONCLUSION: High power setting (90 W) APC showed to be safe and effective. The effects persist at a mean follow-up period of two years with a comparable cost in term of complications with respect to standard power settings. Further studies with greater number of patients are required to confirm these results and to assess if ablation reduces the incidence of malignant progression.     

Banding without resection (endoscopic mucosal ligation) as a novel approach for the ablation of short-segment Barrett's epithelium: results of a pilot study

OBJECTIVES: During an endoscopic variceal ligation, we banded a varix with an overlying tongue of Barrett's epithelium (BE). One month later, the tongue was no longer visible, suggesting that banding could be used to eradicate BE. AIM: To assess the safety and efficacy of banding without resection (BWR) using a variceal banding device for eradicating BE. METHODS: From April 2004 through September 2005, 30 patients with BE were treated with BWR plus omeprazole 20 mg t.i.d. BWR was repeated monthly until two consecutive endoscopic and histological examinations showed no BE. Thirty Barrett's patients treated with omeprazole 20 mg t.i.d. alone served as a control group. RESULTS: The BWR treatment group comprised 29 patients with short-segment BE (SSBE) and one with long-segment disease, whereas all 30 of the control patients had SSBE. During a median follow-up of 16.9 months (range 10-24 months), complete eradication of BE was achieved in 29 of 30 patients (97%) in the BWR group. In contrast, BE persisted in all 30 control patients during the same period (P < 0.0005). The mean total number of bands applied per patient was 6.1 (range 1-14) and the mean number of sessions for complete eradication was 3.1 (range 1-7). Adverse events included only mild chest pain and dysphagia that resolved within days. CONCLUSIONS: BWR appears to be a safe, effective, simple, and widely available technique for eradicating SSBE. This is a pilot study and we do not recommend the ablation of nondysplastic BE at this time. Further studies are needed.     

Early experience with radiofrequency energy ablation therapy for Barrett''s esophagus with and without dysplasia

Radiofrequency (RF) ablation using the HALO(360) system combined with proton pump inhibitor (PPI) therapy is a new treatment for Barrett's esophagus (BE). We assessed the safety and effectiveness of this combination therapy at a community-based, BE referral center. After symptom evaluation, endoscopy and histologic assessment, esophageal motility, pH monitoring on PPI, computed tomography, endoscopic ultrasonography and mucosal resection for nodules, we performed HALO(360) ablation followed by twice daily PPI and 3-monthly surveillance for up to 12 months. If metaplasia or dysplasia were present at follow-up, the patients received a second ablation. Thirteen patients (12 male) were treated, three with high-grade dysplasia, four with low-grade and six with non-dysplastic intestinal metaplasia. The mean baseline BE length was 6 cm (range 2-12); nine patients had an hiatal hernia and two had a prior fundoplication. Esophageal pH < 4.0 for < 4% of time was achieved only in 5/13 patients. A mean of 1.4 ablation sessions were performed, without serious adverse events or strictures. Complete eradication of BE was achieved in 6/13 (46%) patients. The mean endoscopic surface regression was 84% (from a mean length of 6 +/- 1 cm to 1.2 +/- 0.5 cm, P < 0.001). Complete elimination of dysplasia was achieved in 5/7 (71%) patients. Ablation efficacy was better in those patients who had maximal pH control (P < 0.05). HALO(360) ablation of BE with or without dysplasia is safe, well-tolerated and effective in the community setting. Follow-up ablation further reverses residual BE or dysplasia.     

Surveillance and survival in Barrett's adenocarcinomas: a population-based study

BACKGROUND & AIMS: Guidelines recommend periodic endoscopic surveillance of Barrett's esophagus (BE) patients to detect and treat early esophageal adenocarcinomas; however, no trials or population-based studies exist. We evaluated the association between endoscopic surveillance of BE and survival among esophageal/gastric cardia adenocarcinoma patients. METHODS: We studied a cohort of 23 BE patients, among 589 esophageal or gastric cardia adenocarcinoma patients diagnosed between 1990-1998 at Northern California Kaiser Permanente (a large health maintenance organization). We measured the presence of BE, detection of cancer by endoscopic surveillance, cancer stage, mortality, and potential confounders. RESULTS: BE was diagnosed in 135 of 589 adenocarcinoma patients, with 23 BE patients diagnosed greater than 6 months before cancer was diagnosed. Among these 23 patients, 73% of the surveillance-detected cancer patients (n = 15) were alive at the end of follow-up, compared with none of the patients without surveillance-detected cancers (n = 8; P = 0.001). All surveillance-detected cancer patients had low-stage disease and none died directly from cancer. The surveillance/survival association was not substantially altered by stratification for age at BE diagnosis or other potential confounders. CONCLUSIONS: Surveillance-detected BE-associated adenocarcinomas were associated with low-stage disease and improved survival. Additional studies are needed to evaluate potential biases and whether screening/surveillance programs decrease mortality among all patients in surveillance. Few patients (3.9%) had a BE diagnosed before their cancer. Thus, even if current surveillance techniques are effective, they are unlikely to substantially impact the population's mortality from esophageal cancer; better methods are needed to identify at risk patients.     

Gas-related symptoms after laparoscopic 360° Nissen or 270° Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity

BACKGROUND: Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms. AIMS: Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms. PATIENTS AND METHODS: In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain. RESULTS: Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch. CONCLUSION: Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.     

High‐resolution manometry findings in symptomatic post‐Nissen fundoplication patients with normal endoscopic configuration

The aim of this study was to investigate high‐resolution manometry (HRM) findings in symptomatic post‐fundoplication patients with normal endoscopic configuration. A retrospective review of a prospectively maintained database was conducted to identify patients who underwent evaluation with HRM and endoscopy for symptom evaluation after previous fundoplication. Study period extends from September 2008 to December 2012. Only patients with complete 360° fundoplication (Nissen) were included, and patients with partial fundoplication were excluded. Patients with endoscopic abnormality or patients who underwent Collis procedure were also excluded. Additionally, contrast study and 24‐hour pH study if done were reviewed. Symptoms were graded using a standard questionnaire with symptoms graded on a scale of 0–3. Symptom grade 2 or 3 was considered a significant symptom. One hundred seventy‐nine symptomatic patients with previous Nissen fundoplication underwent HRM and endoscopy during the study period. Of these, 136 patients were excluded (51 had recurrent hiatal hernia, 2 had disrupted fundoplication, 68 had slipped fundoplication, 10 had twisted fundoplication, 2 had esophageal stricture, and 3 had Collis procedure). Remaining forty‐three patients met inclusion criteria (mean age of 56.0 ± 14.8, 32 females).The most common symptom was dysphagia (67%). Patients with dysphagia had a significantly longer length of distal esophageal high pressure zone (HPZ) and a higher integrated relaxation pressure (IRP) than patients without dysphagia (P = 0.020, 0.049). Especially, patients who had shorter HPZ (≤2 cm) were less likely to have significant dysphagia. Twenty‐three patients (53%) had heartburn. There was no significant difference in HRM findings between patients with and without heartburn. Only 4 of 28 patients with concomitant pH study showed abnormal DeMeester score (>14.7), and there was no correlation between results of pH study and lower esophageal sphincter pressure/length and IRP. Longer HPZ complex length and higher IRP as measured with HRM is associated with post‐Nissen fundoplication dysphagia in patients with normal endoscopic configuration. No HRM parameters are associated with reported heartburn or a positive pH score.