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Ann Thorac Surg 2004;77:393-396
© 2004 The Society of Thoracic Surgeons
a Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
* Address reprint requests to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905, USA.
e-mail: deschamps.claude{at}mayo.edu
Presented at the Poster Session of the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
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Abstract |
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 Top Abstract IntroductionMaterial and methodsResultsCommentReferences |
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METHODS: From January 1995 through December 2000, 49 patients with BE (35 men and 14 women) underwent laparoscopic antireflux surgery. Median age was 54 years (range, 28 to 85 years). No patient had high-grade dysplasia; 6, however, had low-grade dysplasia. All 49 patients had gastroesophageal reflux symptoms. Heartburn was present in 41 patients (84%), dysphagia in 16 (33%), epigastric or chest pain in 9 (18%), and other symptoms in 16 (33%). A Nissen fundoplication was performed in 48 patients and a partial posterior fundoplication in 1. Forty-one patients (84%) had concomitant hiatal hernia repair.
RESULTS: There were no deaths. Complications occurred in 2 patients (4%). Follow-up was complete in 48 patients (98%) and ranged from 1 to 81 months (median, 29 months). Functional results were classified as excellent in 33 patients (69%), good in 9 (19%), fair in 5 (10%), and poor in 1 (2%). Thirty-three patients (67%) underwent postoperative surveillance esophagoscopy with biopsy. Nine patients (18%) had total regression of BE and 3 (6%) had a decrease in total length. In the 6 patients with preoperative low-grade dysplasia, dysplasia was not found in 4, remained unchanged in 1, and progressed to in situ adenocarcinoma in 1.
CONCLUSIONS: Laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE may occur in some patients, the possibility of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Therefore, endoscopic surveillance should continue.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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The records of these patients were retrospectively analyzed for age, gender, symptoms, diagnostic evaluation, indications for operation, operative procedure, functional results, progression of BE, and development of esophageal carcinoma. Postoperative esophageal surveillance consisted of endoscopic examination of the esophagus and stomach with four quadrant biopsies every 2 cm throughout the involved length of suspected areas of metaplasia. Surveillance biopsies were examined for the presence of dysplasia and(or) carcinoma by two experienced pathologists. Patients were questioned at follow-up for symptoms of reflux, dysphagia, pain, diarrhea, or bloating. Functional results were considered excellent if the patient was taking no medication and eating a general diet without symptoms; good if symptoms were minimal and medication and(or) esophageal dilatation was not required; fair if symptoms were improved but medication and(or) esophageal dilatation was required, and poor if symptoms were unchanged or worse. The Mayo Foundation's Institutional Review Board approved this study.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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All patients underwent preoperative esophagogastroduodenoscopy and all had biopsy proven BE. The BE was circumferential in 28 patients (57%) and patchy in 21 (43%). The median length of BE was 3 cm and ranged from 2 to 17 cm. Lengths greater than or equal to 3 cm were found in 26 patients (53%). Other concomitant findings included a sliding hiatal hernia in 40 patients (82%), esophageal ulcer in 8 (16%), esophagitis in 7 (14%), esophageal stricture in 6 (12%), gastric ulcer in 2 (4%), and esophageal polyps in 2 (4%). No patient had high-grade dysplasia; however, low-grade dysplasia was found in 6. An upper gastrointestinal barium swallow was performed in 19 patients (39%) and demonstrated a sliding hiatal hernia in 13, esophageal stenosis in 1, a paraesophageal hiatal hernia in 1, and was normal in 4. Esophageal motility was done in 34 patients (69%), which demonstrated a reduced lower esophageal sphincter pressure in 17 and abnormal peristalsis in 10 (low amplitude peristalsis in 8, nutcracker esophagus in 1, and nonspecific changes in 1). Twenty-four hour esophageal pH monitoring was performed in 10 patients (20%) and all had an extended period of time where the pH was below 4.
All patients were managed initially with a medical regimen that consisted of lifestyle and dietary modifications in all 49 patients, proton pump inhibitors in 45 patients, H2-blockers in 25 patients, and antacids in 17. Median duration of medical management before LARP was 5 years and ranged from 1 to 16 years.
The most common indication for LARP (Table 1) was the presence of symptoms refractory to medical therapy (47 patients, 96%). The median time interval from diagnosis of BE to LARP was 9.5 months and ranged from 1 day to 15 years. Laparoscopic antireflux procedure was performed at the time of initial diagnosis in 17 patients and more than 3 months after diagnosis in the remaining 32.
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Follow-up was complete in 48 patients (98%) and ranged from 1 to 81 months (median, 29 months). All patients are currently alive. Functional results were considered excellent in 33 patients (69%), good in 9 (19%), fair in 5 (10%), and poor in 1 (2%). Persistent symptoms are listed in Table 2. Additional esophageal procedures were required in 2 patients. One of these patients underwent endoscopic gastroesophageal plication at 20 months for recurrent reflux symptoms due to a slipped fundoplication. The second patient was treated with photodynamic therapy 10 months postoperatively for persistent dysplasia. This patient developed a stricture 1 month later and multiple esophageal dilatations were necessary to improve swallowing.
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Of the 6 patients with low-grade dysplasia, complete regression of the dysplasia occurred in 4 (67%), progression to in situ adenocarcinoma in 1 (at 40 months), and there was no change in one. The patient with in situ adenocarcinoma subsequently underwent esophageal resection and was found to have a T0N0M0 cancer. This patient is currently alive, free of disease 20 months after esophagectomy. The incidence of developing adenocarcinoma among the 49 patients was one per 72.5 patient-years of follow-up. One other patient with no dysplasia preoperatively developed low-grade dysplasia 24 months after LARP and currently is asymptomatic and under surveillance.
Forty-three patients (88%) underwent a barium swallow after LARP. Findings consistent with a fundoplication were observed in 38 patients (78%), recurrent hiatal hernia in 4 (8%), esophageal stenosis in 3 (6%), gastroesophageal reflux in 2 (4%), and a slipped Nissen fundoplication in 1.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Currently, most clinicians initially treat BE and its associated symptoms with proton pump inhibitors, and, if successful, will continue this treatment for prolonged periods of time [5]. Refractory symptoms, however, are considered an indication for surgical intervention [5], and this was the indication in all but 2 of our patients. Surgical intervention is also indicated if complications such as ulcer, stenosis, or bleeding occur [5]. Controversy, however, exists as to whether asymptomatic patients with BE should be managed surgically [5, 6]. Because complete elimination of symptoms while on medical treatment does not guarantee total absence of reflux [7, 8], fundoplication may offer the most predictable method of eliminating the dangerous contribution of acid combined with bile salts and pancreatic enzymes [9].
Yau and associates have suggested that patients with BE may represent a group of patients with worse postoperative outcomes following antireflux surgery than patients without BE [10]. Our results, however, demonstrate that the outcome of LARP is similar for patients with BE as compared with other patients with GERD [11, 12]. Others have also reported similar findings [8, 10, 13–15].
Not every patient with BE is a candidate for LARP. During the six years of this study, LARP was performed in only 60% of our patients who were otherwise candidates for an antireflux procedure. While several potential patient-related benefits are possible with LARP, compared to an open approach with either laparotomy or thoracotomy [1, 2, 12], our preference has been an open procedure for patients with history of a previous repair, a large diaphragmatic hernia, or a shortened esophagus [2, 16].
Regression of BE did occur in our study. Nine patients (19%) had total regression and 3 (6%) had partial. In addition, regression of low-grade dysplasia to no dysplasia occurred in 4 of 6 patients. Although regression of BE following antireflux surgery had occasionally been reported in the past [17–21], a number of recently published studies have also demonstrated complete regression [6, 13, 15, 22]. Factors responsible for complete regression, however, have not yet been determined and regression thus remains an unpredictable event [15].
Documentation of mucosal changes following fundoplication can be difficult. Sampling errors at endoscopy, difficulty in identifying the exact location of the esophagogastric junction, and interobserver variability among individual endoscopists make identification of mucosal changes difficult. Although only one of our patients developed in situ adenocarcinoma during follow-up, whether antireflux surgery provided any protection against subsequent development of adenocarcinoma in our series is still unclear. We previously reported on a group of 113 patients with BE treated with an antireflux procedure [23], 3 of whom developed adenocarcinoma postoperatively. All 3 of these adenocarcinomas were diagnosed in the early postoperative period suggesting that the carcinogenic process was active before the antireflux procedure [5]. Others also have reported adenocarcinoma developing in patients after a successful antireflux procedure [19]. While current information does not prove that surgery is superior to medical treatment in the prevention of esophageal cancer [24, 25], there is a growing body of evidence suggesting that surgery is superior to medical therapy in preventing the progression of BE to adenocarcinoma [6, 13–15].
Currently, we recommend surveillance in all patients with BE following an antireflux procedure [3, 5, 26, 27]. Newer treatment modalities, such as thermal ablation and photodynamic therapy, are presently under investigation, but these are not yet ready for routine clinical use [28]. Combining these new modalities with an antireflux procedure may prove to be successful in eradicating BE and thus preventing the development of cancer in the future.
In conclusion, laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE and reversal of dysplasia may occur in some patients, the risk of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Endoscopic surveillance should, therefore, be continued in these patients.
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References |
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  A. G. Casson, K. Madani, S. Mann, R. Zhao, B. Reeder, and H. J. Lim Does previous fundoplication alter the surgical approach to esophageal adenocarcinoma? Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 1097 - 1102. [Abstract] [Full Text] [PDF]
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