Laparoscopic surgical treatment for patients with short- and long-segment Barrett's esophagus: which technique in which patient?

Laparoscopic antireflux surgery is very successful in patients with short-segment Barrett's esophagus (BE), but in patients with long-segment BE, the results remain in discussion. In these patients, during the open era of surgery, we performed acid suppression + duodenal diversion procedures added to the antireflux procedure (fundoplication + vagotomy + antrectomy + Roux-en-Y gastrojejunostomy) to obtain better results at long-term follow-up. The aim of this prospective study is to present the results of 3 to 5 years' follow-up in patients with short-segment and long-segment or complicated BE (ulcer or stricture) who underwent fundoplication or the acid suppression-duodenal diversion technique, both performed by a laparoscopic approach. One hundred eight patients with histologically confirmed BE were included: 58 patients with short-segment BE, and 50 with long-segment BE, 28 of whom had complications associated with severe erosive esophagitis, ulcer, or stricture. After surgery, among patients treated with fundoplication with cardia calibration, endoscopic erosive esophagitis was observed in 6.9% of patients with short-segment BE, while 50% of patients with long-segment BE presented with positive acid reflux, persistence of endoscopic esophagitis with intestinal metaplasia, and progression to dysplasia (in 5% of cases; P = 0.000). On the contrary, after acid suppression-duodenal diversion surgery in patients with long-segment BE, more than 95.6% presented with successful results regarding recurrent symptoms and endoscopic regression of esophagitis. Regression of intestinal metaplasia to the cardiac mucosa was observed in 56.9% of patients with short-segment BE who underwent fundoplication and in 61% of those with long-segment BE treated with the acid suppression-duodenal diversion procedure. Patients with long-segment BE who experienced fundoplication alone presented no regression of intestinal metaplasia; on the contrary, progression to dysplasia was observed in 1 case (P = 0.049). Patients with short-segment BE can be successfully treated with fundoplication, but for patients with long-segment BE, we suggest performance of fundoplication plus an acid suppression-duodenal diversion procedure.     

Effect of duodenal diversion on low-grade dysplasia in patients with Barrett’s esophagus: Analysis of 37 patients

It is well known that in patients with Barrett’s esophagus (BE), even after antireflux surgery, intestinal metaplasia can progress to dysplasia or even adenocarcinoma. However, the opposite—that is regression of dysplastic changes to intestinal metaplasia after antireflux surgery—has been documented in only a few reports. The objective of this study was to determine the effect of a duodenal diversion operation on lowgrade dysplasia in patients with BE. Thirty-seven patients with either short-segment (n = 12) or longsegment (n = 25) BE underwent antireflux surgery plus either a duodenal switch procedure (13 patients) or a partial distal gastrectomy with Roux-en-Y gastrojejunal anastomosis (24 patients). All of them were subjected to complete clinical, endoscopic, histologic, manometric, and 24-hour pH testing, and 24-hour monitoring of the bile exposure in distal esophagus. There were no deaths in this series, and morbidity occurred in only one patient (2.7%). Manometric assessment after surgery showed a significant increase in sphincter pressure, abdominal length, and total length (P < 0.001). Acid reflux showed a significant decrease after surgery, and duodenal reflux was completely abolished in all except one patient. Follow-up in all patients was longer than 24 months (mean 60 months). Three to four endoscopic procedures were performed after surgery in each patient, and several biopsy specimens were taken distal to the squamo-columnar junction during each endoscopic procedure. Eleven patients (91%) with short-segment BE demonstrated histologic regression to either cardiac mucosa or nondysplastic intestinal metaplasia. Among the 25 patients with long-segment BE, there was a 62.5% rate of histologic regression to nondysplastic epithelium when the length of BE measured between 31 and 99 mm and 33 % histologic regression when the length of BE was 101 mm or more. There were no cases of progression to high-grade dysplasia or adenocarcinoma. The endoscopic length of the columnar-lined esophagus did not change late after surgery. In 65% of patients with BE, antireflux surgery, gastric acid reduction, and duodenal diversion produced histologic regression of low-grade dysplasia to nondysplastic mucosa. This effect was even more pronounced when the length of BE was shorter. It seems to be permanent, and no progression to high-grade dysplasia or adenocarcinoma has occurred.     

Effect of gastric bypass on barrett’s esophagus and intestinal metaplasia of the cardia in patients with morbid obesity

Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett’s esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett’s esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m² to 29.4 kg/m² 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett’s esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.     

Efficacy of laparoscopic antireflux surgery in patients with Barrett's esophagus

BACKGROUND: Laparoscopic antireflux surgery (LARS) corrects significant physiologic and anatomic abnormalities in patients with gastroesophageal reflux disease (GERD); however, debate exists whether LARS prevents recurrent symptoms and malignant transformation in patients with Barrett's esophagus (BE). This study compared clinical outcomes after LARS in patients with and without BE. METHODS: From 1994 to 2001, 448 patients who underwent LARS were studied. Of these, 68 (15%) had preoperative evidence of BE with low-grade dysplasia in 3 (4%), and 380 (85%) were without BE. Mean postoperative follow-up was more than 30 months in each group. RESULTS: After LARS, there was equivalent reduction in acid reduction medication use and typical GERD symptoms in both groups. Anatomic failures developed in 12% of patients with BE and in 5% of those without BE (P = 0.05). Upper endoscopy with biopsies was obtained in 50 of 68 patients (74%) with BE at 37 +/- 22 months postoperatively. Intestinal metaplasia was no longer present in 7 of 50 (14%) BE patients, and low-grade dysplasia regressed to nondysplastic Barrett's in 2 of 3 patients. New low-grade dysplasia developed in 1 BE patient (2%) at postoperative endoscopic surveillance. No BE patients developed high-grade dysplasia or adenocarcinoma. CONCLUSIONS: After LARS, patients with BE have symptomatic relief and reduction in medication use equivalent to non-BE patients. Regression of intestinal metaplasia and the absence of progression to high-grade dysplasia or adenocarcinoma suggest that LARS is an effective approach for the management of patients with Barrett's esophagus. The higher failure rate of LARS in BE is of concern and mandates ongoing follow-up of these patients.     

Dysplasia and Adenocarcinoma After Classic Antireflux Surgery in Patients With Barrett’s Esophagus: The Need for Long-Term Subjective and Objective Follow-Up

OBJECTIVE: To assess the clinical, endoscopic, and functional results in a group of patients with Barrett's esophagus undergoing classic antireflux surgery in whom dysplasia and adenocarcinoma were found at a late objective follow-up. SUMMARY BACKGROUND DATA: There have been isolated reports of patients with Barrett's esophagus undergoing antireflux surgery who show dysplasia or even adenocarcinoma on follow-up. METHODS: Of 161 patients undergoing surgery, dysplasia developed in 17 (10.5%) at late follow-up and adenocarcinoma developed in 4 (2.5%). These 21 patients represent the group assessed and were compared with 126 surgical patients with long-segment Barrett's in whom dysplasia did not develop. They were evaluated by clinical questionnaire, multiple endoscopic procedures and biopsy specimens, 24-hour pH studies, and 24-hour bilirubin monitoring. RESULTS: Of the 17 patients with dysplasia, 3 were asymptomatic at the time that dysplastic changes appeared; all patients with adenocarcinoma had symptoms. Two patients (12%) in the dysplasia group had short-segment Barrett's; all patients with adenocarcinoma had long-segment Barrett's. Manometric studies revealed an incompetent lower esophageal sphincter in 70% of the dysplasia group, similar to nondysplasia patients with recurrence, and in 100% of the adenocarcinoma group. The 24-hour pH study showed pathologic acid reflux in 94% of the patients with dysplasia, similar to patients with recurrence without dysplasia, whereas bilirubin monitoring showed duodenal abnormal reflux in 86% of the patients. Among patients with dysplasia, three different histologic patterns were identified. All patients with adenocarcinoma had initially intestinal metaplasia, with appearance of this tumor 6 to 8 years after surgery. CONCLUSIONS: Patients with Barrett's esophagus who undergo antireflux surgery need close and long-term endoscopic and histologic surveillance because dysplasia or even adenocarcinoma can appear at late follow-up. Metaplastic changes from fundic to cardiac mucosa and then to intestinal metaplasia and later to dysplasia or adenocarcinoma can clearly be documented. There were no significant differences in terms of clinical, endoscopic, manometric, 24-hour pH, and bilirubin monitoring studies between patients with recurrence of symptoms without dysplastic changes, and patients with dysplasia. Therefore, the high-risk group for the development of dysplasia is mainly the group with failed antireflux surgery.     

Predictive factors of Barrett esophagus: multivariate analysis of 502 patients with gastroesophageal reflux disease.

HYPOTHESIS: Risk factors for the presence and extent of Barrett esophagus (BE) can be identified in patients with gastroesophageal reflux disease (GERD). DESIGN: Case-comparison study. SETTING: University tertiary referral center. PATIENTS: Five hundred two consecutive patients with GERD documented by 24-hour esophageal pH monitoring and with complete demographic, endoscopic, and physiological evaluation, divided in groups according to the presence and extent of BE (328 patients without BE and 174 with BE [67 short-segment BE and 107 long-segment BE]). MAIN OUTCOME MEASURES: Clinical, endoscopic, and physiological data, studied by multivariate analysis, to identify the independent predictors of the presence and extent of BE. RESULTS: Seven factors were identified as predictors of BE. They were abnormal bile reflux (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.9-9.7), hiatal hernia larger than 4 cm (OR, 4.1; 95% CI, 2.1-8.0), a defective lower esophageal sphincter (OR, 2.7; 95% CI, 1.4-5.4), male sex (OR, 2.6; 95% CI, 1.6-4.3), defective distal esophageal contraction (OR, 2.2; 95% CI, 1.4-3.5), abnormal number of reflux episodes lasting longer than 5 minutes (OR, 2.2; 95% CI, 1.1-4.6), and GERD symptoms lasting for more than 5 years (OR, 2.1; 95% CI, 1.4-3.2). Only abnormal bile reflux (OR, 4.8; 95% CI, 1.7-13.2) was identified as a predictor of short-segment BE (baseline, no BE). Three factors were identified as predictors of long-segment BE (baseline short-segment BE). They were hiatal hernia larger than 4 cm (OR, 17.8; 95% CI, 4.1-76.6), a defective lower esophageal sphincter (OR, 16.9; 95% CI, 1.6-181.4), and an abnormal longest reflux episode (OR, 8.1; 95% CI, 2.8-24.0). CONCLUSIONS: Among patients with GERD, specific factors are associated with the presence and extent of BE. Elimination of reflux with an antireflux operation in patients with 1 or more of these factors may prevent the future development of BE.     

Barrett’s Esophagus: A Review of the Literature

Barrett’s esophagus (BE) is the premalignant lesion of esophageal adenocarcinoma (EAC) defined as specialized intestinal metaplasia of the tubular esophagus that results from chronic gastroesophageal reflux. Which patients are at risk of having BE and which are at further risk of developing EAC has yet to be fully established. Many aspects of the management of BE have changed considerably in the past 5 years alone. The aim of this review is to define the critical elements necessary to effectively manage individuals with BE. The general prevalence of BE is estimated at 1.6–3% and follows a demographic distribution similar to EAC. Both short-segment (<3 cm) and long-segment (≥3 cm) BE confer a significant risk for EAC that is increased by the development of dysplasia. The treatment for flat high-grade dysplasia is endoscopic radiofrequency ablation therapy. The benefits of ablation for non-dysplastic BE and BE with low-grade dysplasia have yet to be validated. By understanding the intricacies of the development, screening, surveillance, and treatment of BE, new insights will be gained into the prevention and early detection of EAC that may ultimately lead to a reduction in morbidity and mortality in this patient population.     

Long-term clinical and pathologic response of Barrett's esophagus after antireflux surgery

BACKGROUND: The impact of antireflux surgery on outcome in Barrett's esophagus, in particular its effect on both the regression of metaplasia and the progression of metaplasia through dysplasia to adenocarcinoma, remains unclear. This long-term follow-up study evaluated clinical, endoscopic, histopathologic, and physiologic parameters in patients with Barrett's esophagus who underwent antireflux surgery in a specialist unit. METHODS: Between 1985 and 2001, 58 patients with Barrett's esophagus (49 long-segment and 9 short-segment) underwent a Rossetti-Nissen fundoplication, 32 via open procedure and 26 laparoscopically. Symptomatic follow-up with a detailed questionnaire was available in 58 (100%) and follow-up endoscopy and histology in 57 (98%) patients, and 41 patients (71%) underwent preoperative and postoperative 24-hour pH monitoring. RESULTS: At a median follow-up of 59 months, 52 patients (90%) had excellent symptom control, whereas 6 patients (10%) had significant recurrent symptoms and were on regular proton pump inhibitor medication. Seventeen of 41 patients having preoperative and postoperative pH monitoring (41%) had a persistent increase of acid reflux above normal. Thirty-five percent (20 of 57) of patients showed either partial or complete regression of Barrett's epithelium. Six of 8 patients with preoperative low-grade dysplasia showed evidence of regression. Dysplasia developed after surgery in 2 patients, and 2 patients developed adenocarcinoma at 4 and 7 years after surgery. All 4 of these patients had abnormal postoperative acid scores. CONCLUSIONS: Nissen fundoplication provides excellent long-lasting relief of symptoms in patients with Barrett's esophagus and may promote regression of metaplasia and dysplasia. Control of symptoms does not concord fully with abolition of acid reflux. Progression of Barrett's to dysplasia and tumor was only evident in patients with abnormal postoperative acid scores, suggesting that pH monitoring has an important role in the follow-up of surgically treated patients.     

Regression of intestinal metaplasia to cardiac or fundic mucosa in patients with Barrett's esophagus submitted to vagotomy, partial gastrectomy and duodenal diversion. A prospective study of 78 patients with more than 5 years of follow up

BACKGROUND: Regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's (BE) esophagus could alter the natural history of BE. OBJECTIVE: To determine the regression of intestinal metaplasia to cardiac mucosa in patients followed more than 5 years after operation, by repeated endoscopy with biopsy. MATERIAL AND METHODS: This prospective study included 78 patients with BE submitted to combined vagotomy, antrectomy (an antireflux procedure), and Roux-en-Y gastrointestinal reconstruction with more than 60 months follow up. Patients were divided in 3 groups: (1) 31 with short-segment BE (< or =30 mm length); (2) 42 with long-segment BE (31 to 99 mm length); and (3) 5 with extra-long-segment BE (> or =100 mm). Each patient had at least three endoscopic procedures with multiple biopsies during a mean follow up of 95 months (range, 60-220 months). Acid and duodenal reflux were also evaluated. RESULTS: Sixty-four percent of patients with short segment BE had regression to cardiac mucosa at a mean of 40 months after operation. Sixty-two percent of patients with long segment BE had regression to cardiac mucosa at a mean of 47 months postoperatively. No regression occurred in the 5 patients with extra-long segment BE. In 20% of patients, regression to fundic mucosa occurred between 78 to 94 months after surgery. One patient progressed to low grade dysplasia, but no patient progressed to high-grade dysplasia or adenocarcinoma. Acid and duodenal reflux studies demonstrated that in asymptomatic patients, reflux was abolished; 90% of the patients had a Visick grade of 1 or 2. CONCLUSIONS: Vagotomy and antrectomy combined with duodenal bile diversion abolish acid and duodenal reflux into the distal esophagus in patients with BE, which is accompanied by a regression of BE from intestinal to cardiac or fundic mucosa in about 60% of patients. This regression is time dependent and varies directly with the length of BE. The potential for an antineoplastic effect, especially in young patients with long segment BE, suggests that this operation may become an attractive option as a definitive surgical treatment. Patients with short segment BE submitted to this procedure behave similar to patients submitted to Nissen fundoplication, and therefore in these patients, we do not advocate this complex operation.     

The impact of laparoscopic anti-reflux surgery in patients with Barrett’s esophagus

Background

Barrett’s esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD.

Methods

We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE.

Results

Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1–16 years) after surgery. Regression of BE occurred in 18 (22 %) patients while in 6 (7 %) BE progressed to dysplasia or cancer. Thirty-six (43 %) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41 %) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82 %) of 82 patients completed the post-operative questionnaire; 86 % of these patients reported improvement in heartburn and regurgitation.

Conclusions

LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22 % of patients and progression in 7 %. Thus, continued surveillance of Barrett’s is needed after LARS.     

Long-term outcome of antireflux surgery in patients with Barrett's esophagus

OBJECTIVE: To assess the long-term outcome of antireflux surgery in patients with Barrett's esophagus. SUMMARY BACKGROUND DATA: The prevalence of Barrett's esophagus is increasing, and its treatment is problematic. Antireflux surgery has the potential to stop reflux and induce a quiescent mucosa. Its long-term outcome, however, has recently been challenged with reports of poor control of reflux and the inability to prevent progression to cancer. METHODS: The outcome of antireflux surgery was studied in 97 patients with Barrett's esophagus. Follow-up was complete in 88% (85/97) at a median of 5 years. Fifty-nine had long-segment and 26 short-segment Barrett's. Patients with intestinal metaplasia of the cardia were excluded. Fifty patients underwent a laparoscopic procedure, 20 a transthoracic procedure, and 3 abdominal Nissen operations. Nine had a Collis-Belsey procedure and three had other partial wraps. Outcome measures included relief of reflux symptoms (all), patients' perception of the result (all), upper endoscopy and histology (n = 79), and postoperative 24-hour pH monitoring (n = 21). RESULTS: At a median follow-up of 5 years, reflux symptoms were absent in 67 of 85 patients (79%). Eighteen (20%) developed recurrent symptoms; four had returned to taking daily acid-suppression medication. Seven patients underwent a secondary repair and were asymptomatic, increasing the eventual successful outcome to 87%. Recurrent symptoms were most common in patients undergoing Collis-Belsey (33%) and laparoscopic Nissen (26%) procedures and least common after a transthoracic Nissen operation (5%). The results of postoperative 24-hour pH monitoring were normal in 17 of 21 (81%). Recurrent hiatal hernias were detected in 17 of 79 patients studied; 6 were asymptomatic. Seventy-seven percent of the patients considered themselves cured, 22% considered their condition to be improved, and 97% were satisfied. Low-grade dysplasia regressed to nondysplastic Barrett's in 7 of 16 (44%), and intestinal metaplasia regressed to cardiac mucosa in 9 of 63 (14%). Low-grade dysplasia developed in 4 of 63 (6%) patients. No patient developed high-grade dysplasia or cancer in 410 patient-years of follow-up. CONCLUSIONS: After antireflux surgery, most patients with Barrett's enjoy long-lasting relief of reflux symptoms, and nearly all patients consider themselves cured or improved. Mild symptoms recur in one fifth. Importantly, dysplasia regressed in nearly half of the patients in whom it was present before surgery, intestinal metaplasia disappeared in 14% of patients, and high-grade dysplasia and adenocarcinoma were prevented in all.     

Gastroesophageal reflux disease and mucosal injury with emphasis on short-segment Barrett’s esophagus and duodenogastroesophageal reflux

Gastroeosphageal reflux disease has been associated with long segments of Barrett’s esophagus (≥3 cm), but little is known about its association with shorter segments. The aim of this study was to evaluate anatomic and physiologic alterations of the cardia and esophageal exposure to gastric and duodenal juice in patients with short and long segments of Barrett’s esophagus. Furthermore, these patients were compared to each other and to patients with erosive esophagitis and those with no mucosal injury. Two hundred sixty-two consecutive patients with foregut symptoms were divided into the following four groups based on endoscopic and histologic findings: group 1, no mucosal injury; group 2, erosive esophagitis; group 3, short-segment Barrett’s esophagus; and group 4, long-segment Barrett’s esophagus. Esophageal exposure time to acid and bilirubin, lower esophageal sphincter characteristics, and endoscopie anatomy of the cardia were compared between the groups. Patients with short-segment Barrett’s esophagus had elevated esophageal acid and bilirubin exposure, decreased lower esophageal sphincter pressure and length, and a high incidence of hiatal hernia. These abnormalities were similar to those in patients with esophagitis and in general less profound than those found in patients with long-segment Barrett’s esophagus. The length of intestinal metaplasia was higher in patients with a defective lower esophageal sphincter. Short-segment Barrett’s esophagus is a complication of severe gastroesophageal reflux disease and is associated with the reflux of both gastric and duodenal juice similar to that seen in patients with long-segment Barrett’s esophagus. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder

A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). Methods In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/2002. At median follow-up of 53 months (19–110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. Results Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91 % (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily anti-acid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). Conclusion LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in ∼70% of patients and improves typical GERD symptoms in ∼90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.     

High-Energy Laser Therapy of Barrett’s Esophagus: Preliminary Results

We present the preliminary results obtained by our research group utilizing Nd:YAG and diode lasers to treat Barretts esophagus (BE). A total of 15 patients with BE (mean age 58 years) underwent endoscopic laser therapy: 11 with intestinal metaplasia, 2 with low-grade dysplasia, and 2 with high-grade dysplasia. The mean length of BE was 4 cm (range 1–12 cm). Six of these patients also underwent antireflux surgery, and nine were prescribed acid-suppressive medication. Endoscopic Nd:YAG laser treatment was carried out from 1997 to 1999; thereafter, diode laser was employed. The mean follow-up of these patients after the first laser session was 28 months. Patients underwent a mean of 6.5 laser sessions (range 3–17 sessions), with no apparent complications. The mean energy per session was 1705 JJ. Only six of these patients (40%) showed complete endoscopic and histologic remission, but a mean of 77% (SD 23.8%) of the total metaplastic tissue in all these patients was ablated. The percentage of healed mucosa was higher in patients with short-segment BE (92%) (p < 0.05) and in subjects treated by two or more laser sessions per centimeter of BE length (89%) (p < 0.05). All four patients with dysplasia showed histologic regression to nondysplastic BE or to squamous epithelium, without recurrence during a mean follow-up of 30 months. The patients who underwent antireflux surgery and those prescribed pharmacologic treatment had similar results. Nd:YAG and diode laser treatment of BE is a safe, effective procedure; it required two sessions per centimeter of metaplasia; and it achieved complete regression of the dysplasia. Further studies are necessary to quantify its effect on cancer incidence.     

Effect of Roux-en-Y gastric bypass in obese patients with Barrett's esophagus: attempts to eliminate duodenogastric reflux.

BACKGROUND: To assess the effect of Roux-en-Y gastric bypass (RYGB) at a tertiary referral Center of Excellence for bariatric surgery on the length and presence of dysplasia in morbidly obese patients with Barrett's esophagus (BE). Esophageal reflux of gastroduodenal contents (acid, bile) contributes to the development of BE and progression in the dysplasia-carcinoma sequence. Obese patients have a high prevalence of gastroesophageal reflux and might be at an increased risk of developing BE and esophageal adenocarcinoma. The effect of eliminating duodenogastroesophageal reflux on BE is not known. METHODS: We performed a retrospective review of all patients with pre-existing, biopsy-proven, long-segment (>3 cm) BE undergoing RYGB at our institution. Only patients with >1 year of endoscopic, biopsy-controlled follow-up (mean 34 mo) were included. RESULTS: Five patients (3 men and 2 women) were identified. The mean +/- standard error of the mean preoperative length of BE was 6 +/- 2 cm; 2 patients had low-grade dysplasia and 1 indeterminate dysplasia. At the postoperative follow-up (>1 yr) examinations, the length of BE had decreased in 4 patients; the overall length was 2 +/- 1 cm; and only 1 patient had dysplasia. All patients experienced a decrease in the length of BE (n = 4), complete disappearance of BE (n = 2), or improvement in the degree of dysplasia (n = 3). The body mass index had decreased from 43 +/- 4 kg/m(2) to 33 +/- 3 kg/m(2), and all experienced subjective improvement in reflux symptoms postoperatively. RYGB resulted in complete or partial regression of BE in 4 of 5 patients and improvement in reflux symptoms in all. CONCLUSION: Our results suggest that RYGB might be the procedure of choice in morbidly obese patients with BE requiring surgical treatment for gastroesophageal reflux disease.     

Barrett's epithelium after antireflux surgery.

Barrett's epithelium (BE), defined as endoscopically visible, histologically proved intestinal-type epithelium in the esophagus, is considered the ultimate consequence of long-standing gastro(duodeno)esophageal reflux disease (GERD). Recent reports suggest that effective antireflux therapy may promote the regression of this metaplastic process. This study aimed to establish whether antireflux surgery (laparoscopic fundoplication) can induce any endoscopic and/or histologic changes in BE. Thirty-five consecutive cases of BE (11 short-segment [SBE] and 24 long-segment [LBE]) were considered. All patients underwent extensive biopsy sampling before and after surgery (mean follow-up, 28 months; range, 12-99 mo). In all cases, (a) intestinal metaplasia (IM) extension (H&E), (b) IM phenotype (high-iron diamine [HID]), and (c) Cdx2 immunohistochemical expression were histologically scored in the biopsy material obtained before and after fundoplication. After surgery, a significant decrease in IM extension and a shift from incomplete- to complete-type IM were documented in SBE. No significant changes occurred in the LBE group in terms of IM extension or histochemical phenotype. A drop in the immunohistochemical expression of Cdx2 protein was also only documented in the SBE group. Antireflux surgery significantly modifies the histologic phenotype of SBE, but not of LBE.     

Metaplastic columnar mucosa in the cervical esophagus after esophagectomy

OBJECTIVE: To evaluate the pathogenesis of metaplastic processes within the esophagus using a human model in which the exact duration of reflux was known. SUMMARY BACKGROUND DATA: The pathogenesis of Barrett's esophagus (BE) is incompletely understood. Patients undergoing esophagectomy and gastric tube reconstruction represent a good model for studying the pathophysiology of columnar cell metaplasia of the human esophagus because the cervical esophagus is rarely or never exposed to gastric contents before the surgical procedure. METHODS: Thirty-two patients underwent manometry, simultaneous 24-hour pH and bilirubin monitoring, and endoscopy with biopsy 3 to 10.4 years after esophagectomy. The presence of columnar mucosa in the cervical esophagus was confirmed on histologic examination. The findings on endoscopy and histology were related to clinical data and the results of pH and bilirubin monitoring 1 cm proximal to the esophagogastrostomy. RESULTS: Fifteen (46.9%) of the 32 patients had metaplastic columnar mucosa within their cervical esophagus. Metaplasia was significantly more common in patients with a preoperative diagnosis of BE. The length of metaplastic mucosa correlated significantly with the degree of esophageal acid exposure, but the presence of abnormal bilirubin exposure was unrelated to the presence of metaplasia. The prevalence of metaplasia did not change with increasing time. Intestinal metaplasia was found within the columnar-lined segment in three patients 8.5, 9.5, and 10.4 years after esophagectomy. All patients with intestinal metaplasia had abnormal exposure of both acid and bilirubin, but the presence of combined reflux was not significantly higher in these patients compared with patients with nonintestinalized segments of columnar mucosa. CONCLUSIONS: Esophageal columnar metaplasia is a common complication after gastric pull-up esophagectomy. Metaplasia is more likely to develop in patients with previous BE than other patients. Metaplasia develops in response to squamous epithelial injury in predisposed individuals.     

Roux-en-Y long limb diversion as the first option for patients who have Barrett's esophagus

In summary, vagotomy plus antrectomy and the Roux-en-Y procedure is based on the following points: (a) patients who have BE show several foregut abnormalities, including incompetent lower esophageal sphincter, impairment in the esophageal clearance, severe gastroesophageal acid reflux, and frequent duodenoesophageal reflux; (b) late results of classic antireflux procedure in BE are poor with a high recurrence rate owing to a progressive loosening of the wrap; (c) the esophageal damage is produced by the injurious component of the refluxate; and (d) among patients who underwent classic antireflux surgery, a certain proportion developed dysplasia or even adenocarcinoma in the follow-up. The authors have observed that the simple correction of the valve is not enough in many cases, because it does not abolish the gastroesophageal reflux but only diminishes it. In patients who have BE and therefore have impaired esophageal clearance, few reflux episodes can maintain or even induce more damage. With the reduction diversion antireflux procedure, the quality of the corrected valve is secondary, and the main goal is to avoid the reflux of injurious components of the refluxate instead of the refluxate itself, which is almost always impossible. Late results support this hypothesis, and the authors propose this surgical procedure as an alternative treatment in patients who have complicated BE or in patients who have long-segment BE. Among patients who have gastroesophageal reflux and intestinal metaplasia of the cardia or with a noncomplicated short-segment BE, laparoscopic antireflux surgery is the authors' first choice, and only the late objective evaluation of surgical treatment demonstrates which surgical technique is the more adequate to a particular patient who has BE.     

Barrett's esophagus can and does regress after antireflux surgery: a study of prevalence and predictive features

BACKGROUND: To investigate the factors leading to histologic regression of metaplastic and dysplastic Barrett's esophagus (BE). STUDY DESIGN: The study sample consisted of 91 consecutive patients with symptomatic Barrett's esophagus. Pre- and posttreatment endoscopic biopsies from 77 Barrett's patients treated surgically and 14 treated with proton pump inhibitors (PPI) were reviewed. An expert pathologist confirmed the presence of intestinal metaplasia (IM) with or without dysplasia. Posttreatment histology was classified as having regressed if two consecutive biopsies taken more than 6 months apart plus all subsequent biopsies showed loss of IM or loss of dysplasia. Clinical factors associated with regression were studied by multivariate analysis, as was the time course of its occurrence. RESULTS: Histopathologic regression occurred in 28 of 77 patients (36.4%) after antireflux surgery and in 1 of 14 patients (7.1%) treated with PPIs alone (p < 0.03). After surgery, regression from low-grade dysplastic to nondysplastic BE occurred in 17 of 25 patients (68%) and from IM to no IM in 11 of 52 (21.2%). Both types of regression were significantly more common in short (< 3 cm) than long (> 3 cm) segment Barrett's esophagus; 19 of 33 (58%) and 9 of 44 (20%) patients, respectively (p = 0.0016). Eight patients progressed, five from IM alone to low-grade dysplasia and three from low- to high-grade dysplasia. All those who progressed had long segment BE. On multivariate analysis, presence of short segment Barrett's and type of treatment were significantly associated with regression; age, gender, surgical procedure, and preoperative lower esophageal sphincter and pH characteristics were not. The median time of biopsy-proved regression was 18.5 months after surgery, with 95% occurring within 5 years. CONCLUSIONS: This study refutes the widely held assumption that once established, Barrett's esophagus does not change. More than one-third of patients with visible segments of Barrett's esophagus undergo histologic regression after antireflux surgery. Regression is dependent on the length of the columnar-lined esophagus and time of followup after antireflux surgery.     

Short-segment Barrett’s esophagus: A prevalent complication of gastroensophageal reflux disease with malignant potential

The significance of finding specialized intestinal epithelium localized to the region of the gastroesophageal junction is unclear. We tested the hypothesis that short segments of specialized intestinal epithelium are a consequence of gastroesophageal reflux disease and are premalignant. Two hundred forty-one patients with reflux symptoms underwent gastroscopy with rigorous biopsy. Barrett’s esophagus was diagnosed when specialized intestinal epithelium was present on biopsy. Patients with Barrett’s esophagus were subdivided according to the length of Barrett’s mucosa: short-segment Barrett’s (<3 cm) and extended Barrett’s (≥3 cm). Esophageal function was evaluated by manometry and 24-hour pH monitoring. In another 16 patients with small noncircumferential adenocarcinomas, the endoscopic length of Barrett’s mucosa was recorded. Thirty-three patients (14%) had short-segment Barrett’s and 37 (15%) had extended Barrett’s esophagus. Patients with short-segment Barrett’s esophagus had significantly more acid exposure than patients without specialized intestinal epithelium. Eighty-one percent of patients with short-segment Barrett’s esophagus had incresed esophageal acid exposure as did 100% of those with extended Barrett’s esophagus. All lengths of Barrett’s mucosa were associated with poor esophageal sphincter function and reduced contraction amplitudes in the distal esophagus. Twelve percent of patients with short-segment Barrett’s esophagus had dysplasia. The length of Barrett’s mucosa was ≤3 cm in 25% (4 of 16) of patients with early Barrett’s adenocarcinoma. Short-segment Barrett’s esophagus is commonly associated with gastroesophageal reflux disease. Further, short segments of specialized intestinal epithelium are premalignant in nature. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.