HP22FIVE YEAR RESULTS OF A PROSPECTIVE RANDOMISED CONTROLLED TRIAL OF ARGON PLASMA COAGULATION VS ENDOSCOPIC SURVEILLANCE OF PATIENTS WITH BARRETT’S OESOPHAGUS AFTER ANTIREFLUX SURGERY

Background Argon plasma coagulation (APC) has been used to ablate Barrett’s oesophagus, although the long‐term efficacy is unknown. This study reports the 5 year results of APC ablation vs surveillance of Barrett’s in post‐fundoplication patients. Methods 43 post‐fundoplication patients with Barrett’s oesophagus were randomised to either APC ablation of Barrett’s or surveillance. 40 have been followed up with endoscopic surveillance for a mean of 68 months to assess treatment efficacy, safety and the durability of the neosquamous re‐epithelialisation. Results A median of 2.5 (range 1–6) APC treatment sessions was required to reach >95% ablation of Barrett’s. Both groups had a significant (p < 0.0001) reduction in Barrett’s length over the duration of follow‐up, with APC patients having significantly greater length reduction of Barrett’s at last endoscopy compared to the surveillance group (p = 0.0277). At 68 months, 14 of 20 APC patients (70%) continued to have >95% ablation of their Barrett’s, with 8 of 14 (57%) having no macroscopic or histologic evidence of Barrett’s. 4 of 20 surveillance patients (20%) had complete reversal of their Barrett’s, with 3 of 4 (75%) having no macroscopic or histologic evidence for Barrett’s. 2 patients in the APC group developed strictures requiring dilation. 2 patients in the surveillance group developed HGD during follow‐up, while none did in the APC group. Conclusions 40% of post‐fundoplication patients with APC ablation of Barrett’s retain this reversal beyond 5 years. 20% of Barrett’s patients post‐fundoplication regress to normal squamous mucosa. Post‐fundoplication Barrett’s surveillance patients continue to develop HGD, this has not been seen in the APC group.     

Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned

Background

Ablating Barrett’s epithelium may reduce the risk of developing esophageal adenocarcinoma. This study reports the experience of a single surgeon using an endoscopic endoluminal device that delivers radiofrequency energy (the BARRx device) to ablate Barrett’s esophagus.

Methods

All patients who underwent ablation of Barrett’s epithelium with the BARRx system were reviewed for length of Barrett’s metaplasia, presence of high-grade dysplasia, postprocedure complications, completeness of ablation at first follow-up endoscopy, need for additional ablation, completeness of ablation at second follow-up endoscopy, and concomitant performance of a Nissen fundoplication.

Results

Sixty-six patients underwent Barrett’s ablation. The median length of the Barrett’s esophagus was 3 (range, 1–14) cm. Twelve patients (18%) had high-grade dysplasia. There were no immediate procedure-related complications. Four strictures occurred: three in patients with ≥12-cm segments of Barrett’s and one in a 6-cm segment. Twenty-nine of 49 patients (59%) who had planned 3-month follow-up endoscopy had complete ablation. Five patients had planned two-stage ablation. Twenty patients with incomplete ablation had additional ablation. Twenty-seven patients had planned follow-up endoscopy at ≥1 year: 25 of 27 (93%) had biopsy-proven normal esophageal mucosa. The median length of Barrett’s esophagus in patients with initially incomplete ablation was 6 cm, compared with 2 cm in the initially complete ablation patients. Seven Nissen fundoplications were present at the time of ablation, whereas six were performed concomitantly with the ablation without increased difficulty.

Conclusions

Complete ablation of Barrett’s esophagus with radiofrequency endoluminal ablation is achievable in >90% of patients. Patients with longer segments are likely to require additional ablation. Patients with very long segments are at risk for stricture and should be approach cautiously. Performance of a fundoplication is not hindered by concomitant ablation.     

Barrett esophagus: risk factors for progression to dysplasia and adenocarcinoma

OBJECTIVE: To evaluate risk factors for dysplasia and adenocarcinoma development in nondysplastic Barrett mucosa. SUMMARY BACKGROUND DATA: The risk for patients with Barrett esophagus to develop esophageal adenocarcinoma is low, and most patients undergoing surveillance will not develop malignancy. Identification of risk factors may allow for more rational surveillance programs in which patients are stratified according to their individual risk of progressing to dysplasia and invasive adenocarcinoma. METHODS: The development of dysplasia and esophageal adenocarcinoma was studied during long-term endoscopic and histologic surveillance in 140 patients with Barrett esophagus free from dysplasia. Risk factors for progression to dysplasia and adenocarcinoma were evaluated. RESULTS: Median follow-up was 5.8 years. Forty-four patients (31.4%) developed low-grade dysplasia and 7 patients (5%) developed high-grade dysplasia or esophageal adenocarcinoma. Dysplasia development was significantly less common after antireflux surgery compared with conventional medical therapy. Low-grade dysplasia (relative risk = 5.5; 95% confidence interval, 1.1-28.6) and long duration of reflux symptoms (relative risk = 1.3; 95% confidence interval, 1.2-1.7) were independently associated with an increased risk of developing high-grade dysplasia or esophageal adenocarcinoma. CONCLUSIONS: Successful antireflux surgery protects the Barrett mucosa from developing high-grade dysplasia and esophageal adenocarcinoma, possibly by better control of reflux of gastric contents. Low-grade dysplasia is the only clinically useful risk factor that permits stratification of the surveillance intervals according to the risk of the individual patient.     

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication

BACKGROUND: Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described. METHODS: From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months). RESULTS: Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up. CONCLUSION: The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.     

Long-term results of ablation with antireflux surgery for Barrett’s esophagus: a clinical and molecular biologic study

Background

The initial results from ablation therapy for metaplastic/dysplastic Barrett’s esophagus (BE) are promising, but the results of extended follow-up evaluation are seldom reported.

Methods

Neodymium:yttrium–aluminum-garnet laser ablation and successful antireflux surgery for 18 patients with metaplastic BE primarily resulted in the total histologic eradication of BE in 15 patients (83%). After antireflux surgery, the healing of gastroesophageal reflux disease (GERD) was objectively verified in all the patients. At late follow-up evaluation, endoscopy, conventional histology, molecular oxidative stress analyses in comparison with normal control conditions (8-hydroxydeoxyguanosine [8-OHdG], superoxide dismutase [SOD], glutathione [GSH], myeloperoxydase [MP]), and immunohistochemistry (p53, and Cdx2, caudal-related homeobox gene 2, marking intestinal differentiation) of the neosquamous epithelium were performed.

Results

At the end of the follow-up period (range, 3–15?years; mean, 8?years), intestinal metaplasia without dysplasia was detected histologically in eight patients (44%). Six patients had macroscopic BE (mean length, 3.5?cm; range 1–10?cm). The neosquamous epithelium was histologically normal, with no underlying columnar tissue. The fundoplication was endoscopically normal in 14 patients (82%). The 8-OHdG level was higher in the neosquamous epithelium than in the control conditions in the distal esophagus (4.3 vs. 0.52; P?=?0.0002) and the proximal esophagus (1.8 vs. 0.95; P?=?0.006). Likewise, SOD activity was higher in the neosquamous epithelium (0.38 vs. 0.12; P?=?0.0005), whereas MP activity and GSH levels remained normal. Three patients showed slight nuclear p53 expression (typical in normal inflammatory reactions), whereas Cdx2 positivity was confined to one case with recurrent intestinal metaplasia.

Conclusions

The neosquamous mucosa, generated by the ablation of BE and the treatment of GERD with fundoplication, was stable during long-term follow-up evaluation in two-thirds of the patients with initial eradication. It had normal p53 expression and no Cdx2 protein expression. The oxidative stress of the neosquamous esophagus remained high, although the clinical significance of this is unclear.     

Endoscopic treatments for Barrett oesophagus

High grade dysplasia and superficial carcinomas (with no extension under muscularis mucosae) can be indications for endoscopic treatments of Barrett oesophagus. When an endoscopic treatment is considered, a gastroscopy with use of acetic acid and planimetry and the confirmation of high-grade dysplasia by a new examination after PPI treatment and a pathologic second confirmation is needed. For high-grade dysplasia in focalised and visible lesions, an endoscopic resection by EMR or ESD should be proposed: it allows a more accurate pathologic examination and can be an effective curative treatment. After endoscopic resection of visible high grade dysplasia lesions, a complete eradication of Barrett oesophagus may be proposed to prevent dysplasia recurrence. In case of extensive high-grade dysplasia or to eradicate Barrett oesophagus residual lesions, radiofrequency ablation is the preferred endoscopic technique. Photodynamic therapy may also be proposed for more invasive lesions or after other endoscopic techniques with mucosal scars. Surgical oesophagus resection is still recommended for diffuse high-grade dysplasia in young patients or in case of pathologic pejorative criteria in endoscopic resection specimen. In case of Low-grade dysplasia, either endoscopic surveillance should be performed every six or 12 months or radiofrequency ablation could be proposed in the yield of prospective studies.     

Barrett's esophagus and antireflux surgery: a study of a series of 26 patients]

STUDY AIM: The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery. PATIENTS AND METHODS: From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient. RESULTS: Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma. CONCLUSION: Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.     

Management of Barrett esophagus with high-grade dysplasia

High-grade dysplasia in Barrett esophagus is a marker for future development of cancer and for the existence of synchronous cancer. A significant problem in management is intraobserver and interobserver variation in the diagnosis of high-grade dysplasia in Barrett esophagus, the natural history of which is poorly understood; thus, treatment decisions are problematic. The ability to preserve the esophagus with endoscopic mucosal ablation or resection and reduce morbidity of treatment has made endoscopic treatment the mainstay of therapy. Esophagectomy is reserved for treatment failures and for high-grade dysplasia not amenable to less aggressive therapies. This article outlines the data supporting current management strategies.     

Clinical and histologic follow-up after antireflux surgery for Barrett's esophagus.

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett's esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett's esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett's esophagus required preoperative endoscopic evidence of columnar-lined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett's esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett's esophagus. A substantial number of patients with Barrett's esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy.     

High-grade dysplasia within Barrett's esophagus: Controversies regarding clinical opinions and approaches

Barrett's esophagus with high-grade dysplasia is a well-known risk factor for the development of esophageal adenocarcinoma, which has become the predominant form of esophageal cancer in the United States. This review addresses four major fundamental issues that shape our treatment decisions regarding high-grade dysplasia within Barrett's esophagus: (1) the poorly defined natural history of high-grade dysplasia in its progression to adenocarcinoma, (2) the potentially high morbidity and mortality of esophageal resection for high-grade dysplasia, (3) the difficulty in detecting cancer among dysplastic cells during endoscopy, and (4) the controversial role of endoscopic mucosal ablative therapy for high-grade dysplasia. Until there are more accurate surveillance methods, better biochemical or molecular markers in predicting cancerous progression, or more effective minimally invasive methods of treatment, esophagogastrectomy must be considered the standard means of managing patients with Barrett's esophagus and high-grade dysplasia. Regular rigorous systematic surveillance and endoscopic mucosal ablation are alternative treatment options that are available but should be used only under strict conditions. The decision to proceed in a certain direction is quite complex and challenging and ideally requires the feedback of patients who are properly educated about the controversies surrounding this disease.     

Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up

Background

The management of high-grade esophageal dysplasia has included surveillance, endoscopic ablative techniques, and esophagectomy. Herein we describe an alternative treatment, laparoscopic transgastric esophageal mucosal resection.

Methods

Laparoscopic transgastric esophageal mucosal resection was accomplished through an anterior gastrotomy. The mucosa was stripped from the Z-line to the proximal extent of the abnormal epithelium. The gastrotomy then was closed with a linear stapler, and a Nissen fundoplication was performed.

Results

Six patients with high-grade dysplasia of the distal esophagus underwent mucosal resection. After 4 to 7 years of endoscopic surveillance, all patients have regenerated squamous epithelium. One patient developed nondysplastic Barrett's esophagus after 2 years and was treated medically. Two strictures were treated successfully with dilatation.

Conclusions

Laparoscopic transgastric esophageal mucosal resection was a reasonable treatment for high-grade dysplasia in this small sample of patients. This technique is a potential alternative treatment for high-grade dysplasia of the esophagus.     

Diagnosis and Management of Barrett-Related Neoplasia in the Modern Era

Whereas in the past, pathologists were hesitant to diagnose high-grade dysplasia in patients with Barrett esophagus, because this diagnosis prompted esophagectomy, current international consensus is that endoscopic treatment is the management for high-grade dysplasia and intramucosal carcinoma. Furthermore, many centers advocate endoscopic ablation for low-grade dysplasia. As such, establishing a diagnosis of dysplasia has become the key step; separation between the grades of dysplasia is less critical. This article offers some criteria for separating dysplasia from reactive changes, discusses pitfalls in interpreting endoscopic mucosal resection specimens, and outlines management strategies.     

Endoscopic argon plasma coagulation of Barrett mucosa

BACKGROUND: Up to 10% of patients with Barrett's esophagus develop adenocarcinoma of the distal esophagus. Endoscopic surveillance is recommended. We studied the potential of Argon plasma coagulation (APC) for eradication of Barrett's esophagus. METHODS: Indication for APC was the histologic evidence of columnar epithelium with a length of > or = 2 cm, located proximal of the cardia and with the presence of goblet cells. Endoscopic therapy was performed using an Argonbeamer (Beamer 2, Erbe Company, Tübingen, Germany) under i.v. sedation and repeated in intervals of 2-3 weeks with the aim of complete eradication of Barrett's epithelium. One month after macroscopic Barrett eradication, superficial and deep biopsies were obtained every 2 cm in 4 quadrant technique to confirm the endoscopic aspect of complete eradication. RESULTS: We report our results (follow-up median: 12 mths., 3-25) in the first 12 patients (8m/4f, median age 57 yrs., 42-69) in which treatment was completed. In one case there was evidence of moderate dysplasia. A mean of 5 (4-11) sessions were required for complete Barrett eradication in 11 patients (median size of Barrett-segment: 4 cm, range 2-11), in one patient partial regression of 50% was observed treatment was discontinued after 17 sessions while only. Deep biopsies showed subepithelial columnar epithelium islands in one case, recurrence of Barrett occurred in 2 cases after 3 and 6 months. Under APC-treatment, 11/12 patients complained about retrosternal pain and odynophagia. No other complications were observed. CONCLUSION: Our preliminary results indicate that APC is safe and effective to eradicate Barrett's epithelium. Follow-up in a larger number of patients is necessary to assess longterm results (Barrett recurrence, decrease in the incidence of the adenocarcinoma), before APC may generally be recommended.     

Laparoscopic antireflux surgery in the treatment of gastroesophageal reflux in patients with Barrett esophagus

BACKGROUND: Patients with gastroesophageal reflux and Barrett esophagus may represent a group of patients with poorer postoperative outcomes. It has been suggested that such patients should undergo open rather than laparoscopic antireflux surgery. HYPOTHESIS: The laparoscopic approach to antireflux surgery is appropriate treatment for patients with Barrett esophagus who have symptomatic gastroesophageal reflux disease. METHODS: The outcome of 757 patients undergoing laparoscopic surgery for gastroesophageal reflux disease from January 1, 1992, through December 31, 1998, was prospectively examined. Barrett esophagus was present in 81 (10.7%) of these patients (58 men and 23 women). The outcome for this group of patients was compared with that of patients undergoing surgery who did not have Barrett esophagus. RESULTS: The types of operation performed were similar for the 2 patient groups. The mean +/- SD length of columnar mucosa was 47.4 +/- 43.6 mm. The average +/- SD operation time was 79.0 +/- 33.4 minutes. Conversion to open surgery occurred in 6 patients. Postoperative outcomes were as follows. Esophageal manometry and 24-hour pH studies before and after laparoscopic fundoplication demonstrated a significant increase in lower esophageal sphincter resting and residual relaxation pressures and a significant decrease in distal esophageal acid exposure. Four patients have developed high-grade dysplasia or invasive cancer within 4 years of their antireflux surgery, and all of these have subsequently undergone esophageal resection. CONCLUSIONS: The outcome of laparoscopic antireflux surgery is similar for patients with Barrett esophagus compared with other patients with gastroesophageal reflux disease. This suggests that laparoscopic surgery is appropriate treatment for this patient group.     

Impact of antireflux operation on columnar-lined esophagus

BACKGROUND: The effect of antireflux operation on the natural history of columnar-lined esophagus (CLE) is not fully understood. The aim of this study was to assess a single center's experience and review the literature on the impact of antireflux operation on CLE without high-grade dysplasia. STUDY DESIGN: The medical records of 26 patients with CLE but without high-grade dysplasia who underwent antireflux operation in our unit were retrospectively analyzed at longterm followup with detailed endoscopic investigation. Thirteen patients presented with intestinal metaplasia (6 had short segments, and 1 had preoperative laser ablation) and 13 without intestinal metaplasia.For the group of 13 patients presenting with intestinal metaplasia, the mean endoscopic followup was 74.7 months (median 46 months). Three of six with short-segment lesion and two of seven with circumferential involvement had complete regression of intestinal metaplasia (one after laser therapy). None had progression to dysplasia or carcinoma. RESULTS: For the group of 13 patients without intestinal metaplasia, mean endoscopic followup was 43.9 months (median 28 months). One had complete regression of CLE, and none developed intestinal metaplasia during surveillance. CONCLUSIONS: Our study suggests that antireflux operation can alter the natural history of CLE, allowing disease stabilization in a substantial proportion of patients. After antireflux operation, total regression of CLE is possible, but in an unpredictable manner.     

Clinical and histologic follow-up after antireflux surgery for Barrett’s esophagus

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett’s esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett’s esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett’s esophagus required preoperative endoscopic evidence of columnarlined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett’s esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett’s esophagus. A substantial number of patients with Barrett’s esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation).     

Efficacy of Nissen fundoplication versus medical therapy in the regression of low-grade dysplasia in patients with Barrett esophagus: a prospective study

OBJECTIVE: The aim of this study is to compare the effect of medical and surgical treatment on the history of patients with Barrett esophagus (BE) and histologic evidence of low-grade dysplasia (LGD). SUMMARY BACKGROUND DATA: BE is a complication of severe gastroesophageal reflux. It is considered a major risk factor for esophageal adenocarcinoma, which may develop through stages from nondysplastic metaplasia to dysplasia (LGD and high-grade dysplasia). Presently, there are no recommended therapeutic guidelines for patients with LGD. METHODS: Between 1998 through 2003, 6592 patients underwent upper endoscopy; 327 of 6592 (5%) patients had BE, and 35 of 327 (10.7%) had LGD. Nineteen patients with LGD were treated with high-dose proton pump inhibitors, and 16 patients underwent laparoscopic Nissen fundoplication. Endoscopic and histologic follow-up was available in all patients after 18 months. We used multiple logistic regression to examine the effect of the 2 treatments on regression of LGD. RESULTS: LGD was predominant in men (male-to-female ratio: 1.7:1). Mean age was 58 +/- 13.5 years. Sixty percent of patients had no endoscopic evidence of esophagitis. A regression from LGD to BE was observed in 12 of 19 (63.2%) patients in the medical group and in 15 of 16 (93.8%) patients in the surgical group (statistically significant difference). Differences between the 2 groups were statistically significant (P = 0.03). CONCLUSION: The results of our study suggest that surgical treatment may be more effective than medical therapy to modify the natural history of LGD in patients with BE, perhaps because it not only controls acid but also biliopancreatic reflux into the esophagus.     

CAGS and ACS Evidence Based Reviews in Surgery. 38: Guidelines for the management of Barrett esophagus with high-grade dysplasia?

Objective: To address the role of esophageal resection and other approaches that are becoming increasingly adopted for the management of Barrett esophagus with high-grade dysplasia (HGD). Data sources: MEDLINE, Cochrane Library and the Trip databases were searched for the terms “Barrett’s or high-grade dysplasia” and “surgery,” “photo-dynamic therapy,” (PDT) “radiofrequency ablation” (RFA) or a combination of these. Study selection: Studies were selected based on the best evidence supporting these commonly used strategies for HGD. Data extraction: The guideline was divided into 4 major components: endoscopic surveillance, mucosal ablation, endoscopic mucosal resection (EMR) and esophagectomy. Main results: Regarding endoscopic surveillance, HGD is an entity distinct and distinguishable from intramucosal carcinoma, and it does not invariably progress to carcinoma. If there is progression, it can be reliably detected at an early, curable stage. Patients undergoing surveillance are reliable for follow-up and are candidates for further therapy if progression is diagnosed. Regarding mucosal ablation, several methods have been reported for HGD; of these, PDT is the most widely used. Radiofrequency ablation has been introduced into practice and is being studied in many of the same centres that have advocated for PDT (RFA is useful for high-risk surgical patients and typically requires multiple endoscopic sessions for therapy and follow-up.) The EMR method has been used to excise discrete esophageal mucosal nodules that were small, flat or poly-poid in nature and that did not invade deeper than the sub-mucosa. Owing to the frequent multifocality of Barrett esophagus, a concomitant mucosal ablative procedure is often required to assure complete eradication of disease (EMR can evaluate and treat discrete mucosal nodules in the esophagus). Most cancers found incidentally in patients with HGD are cured by esophagectomy. It can be performed safely with an operative mortality approaching 1% (it remains the standard of care for patients deemed to have good operative risk). Conclusion: Given the complexities in decision-making in the management of HGD, the nuances in diagnosis and therapy, and the risks associated with either over- or undertreatment, Barrett esophagus with HGD is best managed in a centre of excellence, preferably with input from experienced surgeons, gastroenterologists and pathologists with a focused interest in treating this disorder.     

Porfimer sodium photodynamic therapy for management of Barrett's esophagus with high-grade dysplasia

Porfimer sodium photodynamic therapy (ps-PDT) for Barrett's esophagus is a powerful endoscopic treatment that can eliminate high-grade dysplasia (HGD) and Barrett's mucosa and reduce the risk of development of cancer in these patients. Ps-PDT typically results in destruction of Barrett's esophagus in the majority of the treated area. However, residual small island of Barrett's mucosa may persist after PDT. Therefore, adjuvant thermal ablation should be available during follow-up endoscopies for ablation of residual islands of Barrett's mucosa. PDT should be applied concurrent with effective proton pump inhibitor therapy. This article provides a practical guide for application of porfimer sodium balloon PDT for management of Barrett's esophagus with HGD. Recommendations are provided for patient selection and screening, delivery of PDT to include light dosimetry, methodology for follow-up endoscopies, as well as discussing the potential side effects and complications.     

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.