Apoptosis in Barrett's oesophagus following antireflux surgery

BACKGROUND: Intestinal metaplasia persists in Barrett's mucosa despite control of reflux. Tissue homeostasis is maintained by the balance between apoptosis and proliferation. There is an unexplained temporary increase in proliferation in patients with Barrett's mucosa after antireflux surgery, and the long-term effect of any therapy in altering this balance remains unclear. The aim of this study was to assess apoptosis in Barrett's oesophagus following antireflux surgery. METHODS: Apoptosis was evaluated in endoscopic biopsy specimens from 19 patients with Barrett's oesophagus 4 years after Collis-Nissen gastroplasty using an in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labelling (TUNEL) method. RESULTS: Intestinal metaplasia had a lower apoptosis index than gastric metaplasia (0.27 versus 2.14 per cent; P < 0.001). After operation there was a steady increase of apoptosis in intestinal metaplasia over time (from 0.23 per cent before operation to 0.42 per cent within 2 years and to 0.59 per cent 4 years after operation; P = 0.015). Patients with persistent acid exposure did not show any increase in apoptosis in comparison with patients without acid exposure (0.41 versus 0.59 per cent; P = 0.91). CONCLUSION: Apoptosis is less in intestinal metaplasia than in gastric metaplasia, although there is an increase after antireflux surgery. Persistent acid reflux may predispose to malignancy.     

Efficacy of Medical Therapy and Antireflux Surgery to Prevent Barrett’s Metaplasia in Patients With Gastroesophageal Reflux Disease

OBJECTIVE: To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS: Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS: Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS: Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.     

Fatal and life-threatening complications in antireflux surgery: analysis of 5,502 operations

BACKGROUND: There have been few comprehensive studies relating to the life-threatening or fatal complications of antireflux surgery. METHODS: Some 5502 antireflux operations were performed in Finland between January 1987 and January 1996 (population approximately 5 million); 3993 procedures (72.6 per cent) were open fundoplications, 1162 (21.1 per cent) laparoscopic fundoplications and 347 (6.3 per cent) other anti-reflux procedures. RESULTS: There were 43 fatal or life-threatening complications (prevalence 0.8 per cent). Twenty-two followed primary open fundoplication (prevalence 0.6 per cent), 15 laparoscopic fundoplication (prevalence 1.3 per cent) (P < 0.05), one refundoplication and five other antireflux procedures. The overall mortality rate was 0.3 per cent. Nine patients (0.2 per cent) died after open fundoplication, one (0.1 per cent) following laparoscopic fundoplication (P = 0.43), one following refundoplication and four after other antireflux procedures. Laparoscopic fundoplication was followed by 14 non-fatal life-threatening complications (prevalence 1.2 per cent), open fundoplication by 13 (prevalence 0.3 per cent) (P < 0.01) and other antireflux procedures by one life-threatening complication (0.3 per cent). CONCLUSION: Laparoscopic fundoplication was associated with more life-threatening complications than open fundoplication. This may compromise the advantages of the laparoscopic technique.     

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.     

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.     

Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.     

Treatment of Barrett''s esophagus by endoscopic laser ablation and antireflux surgery.

OBJECTIVE: The regeneration of intestinal metaplasia by squamous epithelium in 17 patients with Barrett's esophagus after endoscopic laser ablation in a reflux-free environment after successful antireflux surgery was prospectively examined. METHODS: All patients had antireflux surgery, and healing of reflux was verified at postoperative endoscopy and 24-hour esophageal pH monitoring. Thereafter, in 11 patients, the whole Barrett's epithelium was ablated using endoscopic Nd-YAG laser energy in 1 to 8 sessions (mean, 4). The needed energy was 965 to 11,173 joules (mean 4709), or about 1000 joules per centimeter of Barrett's esophagus. Six patients had no laser ablation but were treated by antireflux surgery and served as a control group. RESULTS: In all laser-treated patients, the regenerated epithelium was histologically of squamous type in the tubular esophagus, but two patients still had intestinal metaplasia in the gastric cardia. In controls, the length of Barrett's esophagus and intestinal metaplasia remained unchanged. The length of follow-up was 26 months after the last laser session and 21 months in the control group. CONCLUSIONS: The regenerated esophageal epithelium arising after laser ablation in reflux-free environment surgery is of squamous type. This treatment may have a role in preventing the development of esophageal adenocarcinoma arising in Barrett's esophagus.     

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.     

Radiofrequency ablation offers a reliable surgical modality for the treatment of Barrett's esophagus with a minimal learning curve

Radiofrequency ablation (RFA) has gained popularity as treatment for Barrett's esophagus. Inclusive series of patients from initiation of our Barrett's Therapy Program were studied. Review of patients undergoing RFA for Barrett's was performed from September 2008 to May 2011. Patients' outcomes were recorded and analyzed using standard statistical methods. Seventy patients were treated. Average age was 61 (28-70); 80 per cent were male. Seventy-four per cent had dysplasia; 44 low-grade and eight high-grade. A total of 75.7 per cent of patients had long and 24.3 per cent had short segment Barrett's. Procedures per patient ranged from one to seven. Number of treatments in long- and short-segment groups were not different (P = 0.11). The maximum number of treatments in the short-segment group was five with a median of three (44.3%). For long segment, the maximum of RFA procedures was seven, with a median of three (30.8%). Average procedure time was 20.8 minutes for long and 17.9 minutes for short segment. Mean follow-up was 16.1 (2-38) months. Complete response was accomplished in 81 per cent. There were 93.3 per cent of complete responders in the short-segment group versus 75 per cent in the long (P = 0.24). Complications included dysphagia (1), transient chest and cervical pain (1), and abdominal pain (1). Comparing the first 25 per cent of the RFA procedures to the later 75 per cent or first 50 per cent to second 50 per cent, there was no difference in operative time or complications. Two patients recurred, both in the long-segment group. RFA is a safe and effective means to eradicate Barrett's. By measure of treatment time, complication rate, and efficacy of therapy, there is minimal or no "learning curve" for experienced endoscopists.     

Role of fundoplication in patient symptomatology after laparoscopic antireflux surgery

BACKGROUND: Symptoms following antireflux surgery are often seen as unavoidable sequelae of the operation. The aims were to determine the frequency of new adverse sequelae following antireflux surgery and the preoperative incidence of similar symptoms. METHODS: Patients undergoing fundoplication underwent prospective assessment of symptoms using a structured interview before and 6 months after surgery. In addition to the presence or absence of symptoms, Visick scores, visual analogue scales and a composite dysphagia score were used. RESULTS: Some 312 patients were evaluated. Antireflux surgery significantly diminished the symptoms of heartburn, epigastric pain, regurgitation, bloating, odynophagia, nausea, vomiting, diet restriction, nocturnal coughing and wheezing. In contrast, there was a significant increase in inability to belch, diarrhoea and increased passage of flatus. The symptoms of dysphagia, postprandial fullness or early satiety and anorexia were not significantly altered by antireflux surgery. There was, however, a group of patients who experienced new or worsened dysphagia after surgery and were more likely to do so if they had no dysphagia before surgery (31 per cent) than if dysphagia was present before surgery (19 per cent). Some 93 per cent of patients were satisfied with the overall outcome of the operation. CONCLUSION: The majority of patients undergoing laparoscopic fundoplication for gastro-oesophageal reflux derive symptomatic benefit and are satisfied with the outcome. Many of the so-called postfundoplication sequelae are present before surgery in many patients. Overall, antireflux surgery does not lead to increased dysphagia or bloating.     

Results of laparoscopic antireflux operations in patients who have Barrett's esophagus

In most patients who have Barrett's esophagus and who are undergoing open or laparoscopic antireflux surgery, there is a significant improvement in symptom control that is equivalent to that in patients who have uncomplicated gastroesophageal reflux disease. The requirement for reoperation in patients with Barrett's esophagus may be slightly higher, although in the two laparoscopic series published to date, the rate is still only approximately 6%. How much this will increase with longer follow-up, time alone will tell, but given the good results in approximately 95% of patients operated to date, the authors do not believe that the diagnosis of Barrett's esophagus should be considered a blanket contraindication for laparoscopic antireflux surgery. Clearly, in most patients with Barrett's esophagus, an antireflux operation will not result in regression of Barrett's mucosa. It is still unclear whether antireflux surgery provides any protection against subsequent development of esophageal adenocarcinoma. What is clear, however, is that after antireflux surgery, patients who have Barrett's esophagus are still at risk for developing adenocarcinoma and should remain in surveillance programs. The authors believe that laparoscopic antireflux surgery is a safe and effective approach for the cure of reflux-related symptoms in patients who have Barrett's esophagus.     

Prevention of the neoplastic progression of Barrett's oesophagus by endoscopic argon beam plasma ablation

BACKGROUND: Patients with Barrett's oesophagus have a risk of approximately 1 per 100 patient-years for the development of oesophageal adenocarcinoma. Endoscopic ablation of Barrett's oesophagus has been shown to lead to the regrowth of a 'neo' squamous epithelium if gastro-oesophageal reflux is controlled, but the incidence of subsequent tumour formation is unknown. METHODS: The follow-up of 55 patients who underwent endoscopic ablation of Barrett's oesophagus by argon beam plasma coagulation (ABPC) is reported. Of the 55 patients, nine had low-grade dysplasia, nine had high-grade dysplasia and the remainder had non-dysplastic Barrett's metaplasia. Twelve patients had reflux control by antireflux surgery and the remainder received proton pump inhibitor therapy. Barrett's metaplasia was ablated by ABPC to within 2 cm of the gastro-oesophageal junction. RESULTS: To date, one patient has died and one patient was unable to complete treatment. The remaining patients were followed by regular endoscopic surveillance for a mean of 38.5 months to give a total follow-up of 173.5 patient-years. No malignancy has developed in any patient during follow-up. CONCLUSION: The absence of malignant complications in this study of prophylactic ablation of long-segment Barrett's oesophagus strengthens the argument for endoscopic ablation in the prevention of oesophageal adenocarcinoma.     

The role of uninhibited bladder in antireflux surgery. Special reference to reflux recurrence and diverticulum formation

A retrospective study on antireflux surgery for primary vesicoureteral reflux at Hokkaido University Hospital was performed. One hundred and seventy-nine patients (299 ureters) underwent antireflux surgery in these 17 years and 7 months. When the period was divided into 3, success rate was 96.5, 93.8 and 100 per cent, respectively. Overall success rate was 96.6 per cent. There was a combined failure or complication in 9 patients. The records of these 9 were reviewed in detail. Three were believed to be a technical error: 2 stricture and one persistent reflux. The remaining 6 were all children except one and had no clear reason for failure: 2 persistent reflux and 4 contralateral appearance of reflux ("missing VUR"). Four of these 6 patients were characterized by voiding dysfunction, namely uninhibited bladder. In 3 patients reflux disappeared spontaneously by administration of anticholinergic agent. In many of these, vesical diverticulum formation was also noted to precede or to coincide with recurrence or appearance of reflux. Thus other 3 patients with diverticulum formation after antireflux surgery were added and re-evaluated. All 3 children had voiding dysfunction with uninhibited bladder. Diverticulum formation was believed to be related to uninhibited bladder in at least one child. It seems that the child with uninhibited bladder and reflux is particularly at risk for failure or complication of antireflux surgery. Patients with symptoms of voiding dysfunction deserve a complete evaluation, including cystoscopy and urodynamics.     

Comparison of one dose versus three doses of prophylactic antibiotics, and the influence of blood transfusion, on infectious complications in acute and elective colorectal surgery

In a randomized prospective controlled trial involving 311 patients undergoing acute or elective colorectal surgery, the efficacy and safety of two different single dose and one triple dose regimen of antibiotic prophylaxis, as well as the influence of blood transfusion on postoperative infectious complications, were studied. Postoperative infectious complications occurred in a total of 59 patients (19.0 per cent). There were no major differences between the three treatment groups. Thirty-four patients (10.9 per cent) developed abdominal wound infection, 17 patients (5.5 per cent) intra-abdominal abscess and 16 patients (5.1 per cent) anastomotic leakage. Of 202 patients (65.0 per cent) requiring blood transfusion during hospitalization 57 (28.2 per cent; 95 per cent confidence limits of 23-36 per cent) developed infectious complications, whereas two non-transfused patients (1.8 per cent; 95 per cent confidence limits of 0.2 to 6 per cent; P less than 0.001) developed infectious complications. It is concluded that one single dose of antibiotic prophylaxis in acute and elective colorectal surgery is as protective as a triple dose regimen. The development of infectious complications despite antibiotic prophylaxis is strongly related to blood transfusion.     

Symptomatic and functional outcome after laparoscopic reoperation for failed antireflux surgery

BACKGROUND: The aim was to determine symptomatic and functional outcome after reoperative antireflux surgery for recurrent reflux, persistent dysphagia and severe gas bloat, using a primarily laparoscopic surgical approach. METHODS: This was a retrospective analysis of prospectively collected data from 118 patients, of whom 70 had reoperative surgery for recurrent reflux, 35 for dysphagia and 13 for gas bloat. DeMeester scores before and 1 year after surgery, functional symptoms after surgery and overall patient satisfaction were analysed. RESULTS: Reoperation was completed laparoscopically in 101 patients (85.6 per cent), in 28 after previous open hiatal surgery. The operation was converted from an initial laparoscopic approach to open surgery in 17 patients. One-year follow-up data were available for 104 patients (88.1 per cent). After reoperation for recurrent reflux, 84 per cent had a DeMeester heartburn score of zero or one, and 87 per cent had a regurgitation score of zero or one. After reoperation for dysphagia, 21 of 32 patients had a dysphagia score of zero or one, with improvement observed in 25. All patients undergoing reoperation for severe gas bloat were satisfied with the outcome 1 year after operation. CONCLUSION: Revisional surgery for recurrent reflux using a laparoscopic approach offered high rates of success and patient satisfaction. Swallowing returned to normal in two-thirds of patients after reoperation.     

Laparoscopic antireflux surgery in the treatment of the acid-sensitive oesophagus

BACKGROUND: Approximately 10 per cent of patients referred for 24-h oesophageal pH tests with symptoms suggestive of gastro-oesophageal reflux disease will have a normal endoscopic examination and normal distal oesophageal acid exposure times, but a clear temporal correlation between their symptoms and episodes of acid reflux. These patients have an 'acid-sensitive oesophagus', which forms part of the spectrum of reflux-related conditions. Their response to antireflux surgery has not been reported previously. This study represents a prospective cohort analysis of a clearly defined group of patients with acid-sensitive oesophagus who have undergone laparoscopic antireflux surgery. METHODS: Nineteen patients (nine male and ten female; median age 32 years) underwent laparoscopic antireflux surgery for acid-sensitive oesophagus. All had had an incomplete response to medical therapy. RESULTS: Eighteen of 19 patients were graded Visick I or II at 6 months after operation; all 16 patients followed for 1 year were graded Visick I or II. There were significant falls in DeMeester symptom score (4.0 versus 0.5; P < 0.001), symptom events (20 versus none; P < 0.001), number of reflux episodes (17 versus two; P < 0.001) and overall acid exposure times (1.2 versus 0.3 per cent; P < 0.001) after operation. CONCLUSION: Laparoscopic antireflux surgery is a valid and effective treatment for patients with an acid-sensitive oesophagus. Presented in poster form to the British Society of Gastroenterology, Birmingham, March 2000 and the American Gastroenterological Association, San Diego, May 2000     

Impact of antireflux surgery on Barrett's esophagus

BACKGROUND AND AIMS: The rising incidence of Barrett's carcinoma is a matter of major concern in Western societies. We realized a review of the literature to evaluate the impact of antireflux surgery on prevention of Barrett's carcinoma. METHODS: We used MedLine- and PubMed-based review of the literature published since 1970 on surgical treatment of Barrett's esophagus. RESULTS: There is no report in the literature that describes de novo development of Barrett's metaplasia after successful antireflux surgery. Compared with medical therapy, the risk for malignant degeneration of Barrett's metaplasia is reduced in surgical patients according to some studies. On the other hand, regression of Barrett's metaplasia after antireflux surgery is rare and Barrett's carcinoma after surgery has been observed repeatedly. The combination of antireflux surgery and ablation of metaplastic mucosa in order to obtain regression has led to encouraging preliminary results; however, experience is still limited and numerous studies currently are underway. Dysplastic Barrett's esophagus (BE) is a precancerosis and should not be treated as BE without dysplasia; strategies other than antireflux surgery need to be discussed. CONCLUSION: A prophylactic effect of early antireflux surgery upon de novo development of Barrett's metaplasia is probable. The impact of surgery on malignant degeneration of Barrett's epithelium remains uncertain. Data currently available show no clear benefit of antireflux surgery on cancerogenesis in patients with Barrett's metaplasia.     

Vesicoureteral reflux in adults. A twelve-year study of 122 patients

In a twelve-year study, 122 adults with vesicoureteral reflux were followed for at least one year. Reflux ceased in 21 per cent of those managed medically, in 27 per cent of those treated by a combination of drugs and surgical procedures other than antireflux techniques, and in 95 per cent of those treated by an antireflux procedure. Pyelonephritis occurred or worsened in 14 per cent of the medically treated patients and in none treated by an antireflux procedure. Two patients managed medically died of uremia from chronic pyelonephritis. No patients died after an antireflux operation.     

Surveillance for Barrett's oesophagus in the UK

BACKGROUND: Endoscopic screening for Barrett's oesophagus is being offered without evidence of efficacy Barrett's oesophagus is not an ideal candidate for a screening programme, as the natural history is unclear, uncertainties surround the indication for intervention and the treatment is associated with high morbidity and mortality rates. METHODS: To determine the practices that clinicians employ in the management of Barrett's oesophagus in the UK, postal questionnaires were sent in May 1997 to 297 randomly selected members of the British Society of Gastroenterology asking for details of their current practice. RESULTS: Of 152 respondents, 106 (70 per cent) performed surveillance for Barrett's oesophagus; 46 (30 per cent) did not carry out screening. There was no difference in the practices carried out by physicians or surgeons, teaching or acute general hospital clinicians, or those with an upper gastrointestinal interest. There was a wide disparity in screening interval: just over half (52 per cent) screen at yearly intervals. Only nine (8 per cent) took four quadrant biopsies per 2 cm of Barrett's oesophagus. Nearly half (49 per cent) manage mild dysplasia by increasing the frequency of endoscopy; only seven (7 per cent) prescribed patients a proton pump inhibiting agent. Faced with severe dysplasia, 33 (31 per cent) offered surgery immediately; 22 (21 per cent) simply followed the patient by endoscopy. Those not choosing to perform screening most frequently cited lack of evidence of efficacy as the reason behind their decision. CONCLUSION: There is wide variation in surveillance practices for Barrett's oesophagus. Some methods are ineffectual. The recommendations made by the Barrett's Oesophagus Working Party in 1991 are not followed, possibly because they are not practical. New workable guidelines based on available evidence and a consensus of expert opinion should be established; this was suggested by 38 per cent of respondents who performed screening.     

Does antireflux surgery prevent progression of Barrett's esophagus?

Mechanistic reasoning suggests that since antireflux surgery treats the gastroesophageal reflux that is the major known risk factor for Barrett's esophagus, it should have a beneficial effect on the biology of Barrett's disease. Due to a lack of adequate data, whether this is the case remains uncertain. Most studies, including several large population-based cohort studies, are observational studies that are subject to bias. Selection bias could be present, for example, if the patients undergoing one treatment had worse disease than those undergoing the comparator treatment, which seems possible for antireflux surgery and acid suppression medication therapy. A systematic review also suggests publication bias. The published data indicate that surgeons should not claim that antireflux surgery prevents the progression of Barrett's. Well-conducted prospective studies with postoperative pH studies suggest, however, that effective surgery may reduce the risk of Barrett's progression whereas ineffective surgery provides no benefit.