Effect of antireflux operation on Barrett's mucosa

doi:10.1016/0003-4975(90)90298-K

The Annals of Thoracic Surgery

Volume 49, Issue 4, April 1990, Pages 537-542

https://doi.org/10.1016/0003-4975(90)90298-K Get rights and content

Abstract

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined at histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett' s esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.

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Cited by (187)

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Gastro-oesophageal reflux disease is a common medical problem in developed countries, and is a risk factor for the development of Barrett's oesophagus and oesophageal adenocarcinoma. Both proton pump inhibitor therapy and antireflux surgery are effective at controlling endoscopic signs and symptoms of gastro-oesophageal reflux in patients with Barrett's oesophagus, but often fail to eliminate pathological oesophageal acid exposure. The current available studies strongly suggest that acid suppressive therapy, both pharmacological as well as surgical acid suppression, can reduce the risk the development and progression in patients with Barrett's oesophagus, but are not capable of complete prevention. No significant differences have been found between pharmacological and surgical therapy. For clinical practice, patients should be prescribed a proton pump inhibitor once daily as maintenance therapy, with the dose guided by symptoms. Antireflux surgery can be a good alternative to proton pump inhibitor therapy, but should be primarily offered to patients with symptomatic reflux, and not to asymptomatic patients with the rationale to protect against cancer.
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A fibre optic probe and compact light detection system has been used to monitor the fluence-rate at the tissue surface during 5-aminolaevulinic acid based photodynamic therapy (PDT) of Barrett's oesophagous. The contributions from three specific wavelengths were recorded, corresponding to the combination of therapeutic laser light and fluorescence emission from protoporphyrin IX (635 nm), the fluorescence from an oxidation product of the photosensitiser (670 nm), and the protoporphyrin IX fluorescence alone (705 nm). We have found that light scattering results in an enhancement of the therapeutic fluence-rate, and hence light dose, by approximately 70%. At the onset of therapy the fluorescence provides a 10% contribution to the overall fluence-rate at 635 nm. The dynamics of photosensitiser bleaching could be extracted from the depletion in light signals. By defining a bleaching dose as the 635 nm light fluence delivered over the period during which the photosensitiser fluorescence decays to 1/e³ of its initial value, we find that the average ratio of bleaching to total dose is 33%. Further, the fluorescence contributes approximately 5% of the bleaching light dose. These results suggest that the prescribed period of therapeutic light exposure may be reduced with no loss in clinical efficacy, but with a consequent improvement in patient tolerance to this therapy.
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Regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's (BE) esophagus could alter the natural history of BE.
To determine the regression of intestinal metaplasia to cardiac mucosa in patients followed more than 5 years after operation, by repeated endoscopy with biopsy.
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 (≤30 mm length); (2) 42 with long-segment BE (31 to 99 mm length); and (3) 5 with extralong-segment BE (≥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.
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.
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.
Surgical therapy for Barrett's esophagus
2005, Thoracic Surgery Clinics
The oesophageal mucosa: To barrett's and beyond - the genesis of oesophageal injury and cellular mutations
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^☆: Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11–13, 1989.

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Original articleEffect of antireflux operation on Barrett's mucosa☆

Abstract

Gastroenterology

Gastroenterology

J Thorac Cardiovasc Surg

Am J Surg

Gastroenterology

Gastroenterology

Hum Pathol

Hum Pathol

Ann Thorac Surg

Ann Thorac Surg

Gastroenterology

Gastroenterology

Gastroenterology

Oesophagus lined with gastric mucous membrane

Thorax

Barrett's esophagus: congenital or acquired? An experimental study of esophageal mucosal regeneration in the dog

Surgery

Barrett's esophagus: functional assessment, proposed pathogenesis, and surgical therapy

Arch Surg

Original article
Effect of antireflux operation on Barrett's mucosa☆