Barrett esophagus

RISK OF PRENEOPLASTIC LESIONS IN MUCOSAL PROJECTIONS OF DIFFERENT SIZES OF THE COLUMNAR EPITHELIUM IN THE LOWER ESOPHAGUS

BACKGROUND

Barrett's esophagus is an acquired condition that predisposes to the development of esophageal adenocarcinoma.

AIMS

The aim of this study was to establish an association between the endoscopic and the histopathological findings regarding differently sized endoscopic columnar epithelial mucosa projections in the low esophagus, under 3.0 cm in the longitudinal extent.

METHODS

This is a prospective study, including 1262 patients who were submitted to upper gastrointestinal endoscopy in the period from July 2015 to June 2017. The suspicious projections were measured and subdivided into three groups according to the sizes encountered (Group I: <0.99 cm; Group II: 1.0-1.99 cm; and Group III: 2.0-2.99 cm), and biopsies were then performed.

RESULTS

There was a general prevalence of suspicious lesions of 6.42% and of confirmed Barrett's lesions of 1.17%, without a general significant statistical difference among groups. However, from Groups I and II to Group III, the differences were significant, showing that the greater the lesion, the higher the probability of Barrett's esophagus diagnosis. The absolute number of Barrett's lesions was 7, 9, and 6 for Groups I, II, and III, respectively.

CONCLUSIONS

The findings led to the conclusion that even projections under 3.0 cm present a similar possibility of evolution to Barrett's esophagus. If, on the one hand, short segments are more prevalent, on the other hand, the long segments have the higher probability of Barrett's esophagus diagnosis, which is why biopsies are required in all suspicious segments.

DIAGNOSIS, TREATMENT AND FOLLOW-UP OF BARRETT'S ESOPHAGUS: A SYSTEMATIC REVIEW

BACKGROUND

Barrett's esophagus (BE) is a premalignant condition that raises controversy among general practitioners and specialists, especially regarding its diagnosis, treatment, and follow-up protocols.

OBJECTIVE

This systematic review aims to present the particularities and to clarify controversies related to the diagnosis, treatment and surveillance of BE.

METHODS

A systematic review was conducted on PubMed, Cochrane, and SciELO based on articles published in the last 10 years. PRISMA guidelines were followed and the search was made using MeSH and non-MeSH terms "Barrett" and "diagnosis or treatment or therapy or surveillance". We searched for complete randomized controlled clinical trials or Phase IV studies, carried out with individuals over 18 years old.

RESULTS

A total of 42 randomized controlled trials were selected after applying all inclusion and exclusion criteria. A growing trend of alternative and safer techniques to traditional upper gastrointestinal endoscopy were identified, which could improve the detection of BE and patient acceptance. The use of chromoendoscopy-guided biopsy protocols significantly reduced the number of biopsies required to maintain similar BE detection rates. Furthermore, the value of BE chemoprophylaxis with esomeprazole and acetylsalicylic acid was relevant, as well as the establishment of protocols for the follow-up and endoscopic surveillance of patients with BE based predominantly on the presence and degree of dysplasia, as well as on the length of the follow-up affected by BE.

CONCLUSION

Although further studies regarding the diagnosis, treatment and follow-up of BE are warranted, in light of the best evidence presented in the last decade, there is a trend towards electronic chromoendoscopy-guided biopsies for the diagnosis of BE, while treatment should encompass endoscopic techniques such as radiofrequency ablation. Risks of ablative endoscopic methods should be weighted against those of resective surgery. It is also important to consider lifetime endoscopic follow-up for both short and long term BE patients, with consideration to limitations imposed by a range of comorbidities. Unfortunately, there are no randomized controlled trials that have evaluated which is the best recommendation for BE follow-up and endoscopic surveillance (>1 cm) protocols, however, based on current International Guidelines, it is recommended esophagogastroduodenoscopy (EGD) every 5 years in BE without dysplasia with 1 up to 3 cm of extension; every 3 years in BE without dysplasia with >3 up to 10 cm of extension, every 6 to 12 months in BE with low grade dysplasia and, finally, EGD every 3 months after ablative endoscopic therapy in cases of BE with high grade dysplasia.

Esophageal Function Abnormalities in Patients With Barrett's Esophagus

Various esophageal functional abnormalities have been described in patients with Barrett's esophagus (BE). A significantly higher esophageal acid exposure especially in the supine position has been documented in BE, as compared with the other gastroesophageal reflux disease phenotypes. In addition, weakly acidic reflux and duodenogastroesophageal reflux are more common in BE patients. The presence of Barrett's mucosa reduces esophageal mucosal impedance, occasionally to a level that prevents detection of reflux episodes. Reduced amplitude contractions and lower esophageal sphincter basal pressure are more common in BE patients as compared with the other gastroesophageal reflux disease groups. Ineffective esophageal motility is the most commonly defined motor disorder in BE. Reduced chemoreceptor and mechanoreceptor sensitivity to acid and balloon distention, respectively, have been suggested to explain lack or significantly less reports of reflux-related symptoms by BE patients.

IS THERE A RELATION BETWEEN HELYBACTER PYLORI AND INTESTINAL METAPLASIA IN SHORT COLUMN EPITELIZATION UP TO 10 MM IN THE DISTAL ESOPHAGUS?

Background:

The presence of intestinal metaplasia in the distal esophagus (Barrett’s esophagus) is an important precursor of adenocarcinoma. Knowledge of the risk factors and the process by which the Barrett develops is very important and Helicobacter pylori (HP) can contribute to this development.

Aim:

To analyze the impact of HP in the gastric mucosa with intestinal metaplasia in the distal esophagus in areas of columnar epithelialization smaller than 10 mm in length and epidemiological data on prevalence

Method:

A retrospective study in which were included 373 consecutive patients diagnosed with columnar epithelium in the distal esophagus was done. In all, HP was investigated by urease and histology, exclusion and inclusion factors were applied and patients were divided into two groups: the first grouping the ones without histological diagnosis of Barrett’s esophagus (235-63%) and the second with it (138-37%).

Results:

There was no significant difference between HP and non-HP patients in relation to the probability of having intestinal metaplasia (p=0.587). When related to the general group, there was an inverse association between the bacterium and the columnar epithelia in the distal esophagus. Age (p=0.031), gender (p=0.013) and HP (p=0.613) when related together to intestinal metaplasia showed no significant relation. In isolation, when related to age and gender, regardless of HP, results confirmed that patients in more advanced age and women present a higher incidence of intestinal metaplasia.

Conclusion:

There is an inverse relation between HP and the areas of columnar epithelization in the distal esophagus, regardless of the presence or absence of intestinal metaplasia. Age and gender, regardless of HP, showed higher prevalence in women and in older the number of cases with intestinal metaplasia in the distal esophagus.

[Two-stage treatment of Barrett's esophagus]

OBJECTIVE

To evaluate the results of treatment of Barrett's esophagus using laparoscopic 270° Toupet fundoplication or radiofrequency ablation (RFA) and their combination.

MATERIAL AND METHODS

We have analyzed data for the period 2011-2018. Antireflux surgery was performed in the first group, RFA - in the second group, both procedures were done in the third group. The majority of patients with hiatal hernia underwent cruroraphy, laparoscopic 270° Toupet fundoplication, endoscopic treatment as the second stage was performed in some of them. Patients without hiatal hernia and no signs of reflux underwent RFA without antireflux surgery. Control endoscopic examination was carried out after 3, 6 and 12 months and then annually.

RESULTS

There were 84 patients with Barrett's esophagus. We performed 51 RFA procedures in 47 patients and fundoplication in 71 patients. Antireflux surgery as the first stage was preferred in patients with hiatal hernia (n=60), subsequent radiofrequency ablation (RFA) was performed in 28 of them. Seven patients without hiatal hernia, but with significant gastroesophageal reflux underwent antireflux surgery too. Other 12 patients without hiatal hernia underwent RFA alone. Need for delayed antireflux surgery after endoscopic treatment occurred in 23.5% of patients. Complete regression of metaplasia was noted in 95.2% after 1 procedure and in 100% after 2 procedures. Recurrent metaplasia was registered in 4.3% of patients. Progression to dysplasia was not detected.

CONCLUSION

Two-stage surgical approach including antireflux surgery and radiofrequency ablation in combination with drug therapy is optimal. Endoscopic therapy is recommended for all types and length of metaplasia.

Thoracoscopic vagal-sparing esophagectomy and colonic interposition for caustic stricture

Minimally invasive esophagectomy is an increasing trend in surgery. Thoracoscopic esophagectomy is applicable and an alternative procedure to conventional esophagectomy in patients especially with end-stage benign diseases like caustic stricture. A 33-year-old female patient was admitted to the department of general surgery with dysphagia. The patient was suffering from caustic stricture due to ingestion of hydrochloric acid. A totally thoracoscopic and laparoscopic vagal-sparing esophagectomy and colonic interposition was performed. As a more physiologic alternative, vagal-sparing esophagectomy is the ideal operation for these patients.