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Sánchez-Pernaute A, Pérez-Aguirre E. Gastroesophageal reflux after Roux-en-Y gastric bypass: Is it just related to technical details? Cir Esp 2023; 101 Suppl 4:S58-S62. [PMID: 37952721 DOI: 10.1016/j.cireng.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/28/2023] [Indexed: 11/14/2023]
Abstract
Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device. Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.
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Long-term (18 Years) Results of Patients With Long-segment Barrett Esophagus Submitted to Acid Suppression-duodenal Diversion Operation: Better Than Nissen Fundoplication? Ann Surg 2023; 277:252-258. [PMID: 33470631 DOI: 10.1097/sla.0000000000004760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine late results of AS-DD procedure in long-segment (LSBE) and extralong-segment BE (ELSBE) using subjective and objective measurements to ascertain the histological impact over intestinal metaplasia (IM) and progression to EAC. SUMMARY OF BACKGROUND DATA Barrett esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC), and Nissen fundoplication has proven to be unable to stop mixed reflux among them. Our group proposed a surgical procedure that handles pathophysiological changes responsible for BE. METHODS This prospective study included 127 LSBE and ELSBE subjects submitted to clinical and functional analyses. They were presented to selective vagotomy, fundoplication, partial gastrectomy with Roux-en-Y reconstruction. The changes in IM were determined in both groups. RESULTS Follow-up was completed at a mean of 18 years in 81% of the cases. Visick I-II scores were seen in 88% of LSBE and 65% in ELSBE ( P < 0.01). There was significant healing of erosive esophagitis and esophageal peptic ulcers, and strictures were resolved in 71%. There was 38% of IM regression in LSBE. Two cases in each group progressed to EAC at a mean of 15 years. Pathologic acid reflux was abolished in 91% and duodenal in 100%. There was a regression of low-grade dysplasia to IM in 80%. CONCLUSIONS AS-DD permanently eliminates pathologic refluxate to the esophagus. The progression to HGD/EAC is lower compared to medical treatment, with an 8-fold reduction in LSBE and 2.2-fold in ELSBE. AS-DD seems to influence IM behaviors, and it is a tool that could reduce and delay progression to EAC.
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Braghetto I, Valladares H, Lanzarini E, Musleh M, Csendes A, Figueroa-Giralt M, Korn O. ENDOSCOPIC ABLATION COMBINED WITH FUNDOPLICATION PLUS ACID SUPPRESSION-DUODENAL DIVERSION PROCEDURE FOR LONG SEGMENT BARRETT´S ESOPHAGUS: EARLY AND LONG-TERM OUTCOME. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD 2023; 36:e1760. [PMCID: PMC10510372 DOI: 10.1590/0102-672020230042e1760] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/13/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND: The addition of endoscopic ablative therapy plus proton pump inhibitors or fundoplication is postulated for the treatment of patients with long-segment Barrett´s esophagus (LSBE); however, it does not avoid acid and bile reflux in these patients. Fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy is proposed as an acid suppression-duodenal diversion procedure demonstrating excellent results at long-term follow-up. There are no reports on therapeutic strategy with this combination. AIMS: To determine the early and long-term results observed in LSBE patients with or without low-grade dysplasia who underwent the acid suppression-duodenal diversion procedure combined with endoscopic therapy. METHODS: Prospective study including patients with endoscopic LSBE using the Prague classification for circumferential and maximal lengths and confirmed by histological study. Patients were submitted to argon plasma coagulation (21) or radiofrequency ablation (31). After receiving treatment, they were monitored at early and late follow-up (5–12 years) with endoscopic and histologic evaluation. RESULTS: Few complications (ulcers or strictures) were observed after the procedure. Re-treatment was required in both groups of patients. The reduction in length of metaplastic epithelium was significantly better after radiofrequency ablation compared to argon plasma coagulation (10.95 vs 21.15 mms for circumferential length; and 30.96 vs 44.41 mms for maximal length). Intestinal metaplasia disappeared in a high percentage of patients, and histological long-term results were quite similar in both groups. CONCLUSIONS: Endoscopic procedures combined with fundoplication plus acid suppression with duodenal diversion technique to eliminate metaplastic epithelium of distal esophagus could be considered a good alternative option for LSBE treatment.
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Affiliation(s)
- Italo Braghetto
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Héctor Valladares
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Enrique Lanzarini
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Maher Musleh
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Attila Csendes
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Manuel Figueroa-Giralt
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
| | - Owen Korn
- Universidad de Chile, Faculty of Medicine, Hospital “Dr. José J. Aguirre”, Department of Surgery – Santiago, Chile
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Braghetto I, Korn O, Figueroa-Giralt M, Valenzuela C, Burgos AM, Mandiola C, Sotomayor C, Villa E. LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1678. [PMID: 36102488 PMCID: PMC9462863 DOI: 10.1590/0102-672020220002e1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.
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Alaber O, Mansoor E, Perez LKM, Dumot J, Bhatt A, Chak A. High grade dysplasia or esophageal adenocarcinoma in patients with a history of Roux-en-Y gastric bypass surgery: a case series. Endoscopy 2021; 53:147-151. [PMID: 32663878 DOI: 10.1055/a-1203-5832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the favored bariatric option in patients with gastroesophageal reflux and Barrett's esophagus because it prevents reflux. Weight loss and decreased reflux following RYGB could theoretically minimize the risk of progression to cancer. We aimed to demonstrate the management of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) developing in patients after RYGB. METHODS A prospectively maintained database was searched to identify cases of HGD and cancer in RYGB patients. Charts were reviewed for past history, endoscopic findings, endoscopic therapy, and pathology findings. RESULTS There were five cases where HGD/EAC developed several years after RYGB. The prior bariatric surgery precluded curative esophagectomy, illustrating the management challenges. All but one of the patients were uniquely and successfully managed with endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). CONCLUSIONS RYGB patients are still at risk of developing esophageal cancer. Patients at risk should be screened prior to RYGB and those with Barret's esophagus need to undergo rigorous endoscopic surveillance following surgery. If detected early, EMR and ESD are invaluable in managing those who progress.
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Affiliation(s)
- Omer Alaber
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Emad Mansoor
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - John Dumot
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Braghetto I, Csendes A. FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES? ACTA ACUST UNITED AC 2019; 32:e1440. [PMID: 31460600 PMCID: PMC6713057 DOI: 10.1590/0102-672020190001e1440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/21/2019] [Indexed: 02/02/2023]
Abstract
Background: Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher. Aim: The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication. Method: This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results. Results: In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy. Conclusion: Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, Hospital Clínico "Dr. José J. Aguirre", Faculty of Medicine, University of Chile, Santiago Chile
| | - Attila Csendes
- Department of Surgery, Hospital Clínico "Dr. José J. Aguirre", Faculty of Medicine, University of Chile, Santiago Chile
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Herbella FAM, Schlottmann F, Patti MG. Antireflux Surgery and Barrett's Esophagus: Myth or Reality? World J Surg 2017; 42:1798-1802. [PMID: 29264726 DOI: 10.1007/s00268-017-4394-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It may seem questionable if antireflux surgery still has a role in the management of patients with Barrett's esophagus (BE) in the current era when antireflux surgery is facing a steady decline, obesity is increasing, pharmacologic treatment for gastroesophageal reflux disease (GERD) is in its splendor, and endoscopic techniques are used more frequently. It is questionable if patients with BE should be operated to stop GERD and to prevent cancer. The aim of this study was to determine the role of antireflux surgery in patients with BE. METHODS Literature review. RESULTS The role of antireflux operations is, in fact, very controversial and neglected. BE is a different phenotype of GERD with a distinct pathophysiology linked to severe reflux of bile and acid, due to a marked anatomic disruption of the gastroesophageal barrier. Published series show that a fundoplication adequately controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion antireflux procedure) may prevent esophageal adenocarcinoma. CONCLUSIONS In conclusion, a fundoplication efficiently controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion procedure) may also prevent esophageal adenocarcinoma.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Francisco Schlottmann
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Marco G Patti
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
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Gomez G. The Evaluation and Management of Suspicious Gastric Lesions Following Bariatric Surgery. Surg Clin North Am 2017; 97:467-474. [PMID: 28325198 DOI: 10.1016/j.suc.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Obesity has reached epidemic proportions worldwide and is associated with a higher mortality from several diseases, including adenocarcinoma of the esophagus and of the gastric cardia. Increased body mass index is associated with an increased incidence of gastroesophageal reflux disease (GERD), Barrett metaplasia, and adenocarcinoma of the cardia. Bariatric surgery remains the most effective therapy for morbid obesity and has the potential to improve weight-related GERD. A high index of suspicion is paramount for early detection of foregut neoplasia after bariatric surgery.
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Affiliation(s)
- Guillermo Gomez
- General Surgery, The University of Texas Medical Branch, Galveston, TX, USA.
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Cartwright J, Forbat E, Botha A. Ivor-Lewis oesophagogastrectomy with Roux-en-Y duodenal bypass. Ann R Coll Surg Engl 2016; 98:116-20. [PMID: 26741669 PMCID: PMC5210470 DOI: 10.1308/rcsann.2016.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 11/22/2022] Open
Abstract
Oesophagectomies and gastrectomies are performed predominantly for the treatment of malignant disease. However, in this case series, we describe three patients with benign disease who had a laparoscopic oesophagogastrectomy with gastroduodenal detachment and Roux-en-Y biliary diversion, and discuss the operative feasibility and consequent patient outcomes. Our aim was to modify the procedure using an established reconstruction already practised in gastric and bariatric surgery, thereby preventing operative sequelae that lead to a poor quality of life (eg reflux oesophagitis and vomiting). During the first postoperative year, our first two patients experienced weight loss, indigestion and lower bowel symptoms with no apparent improvement in gastric function compared with a standard gastric tube pull-up reconstruction. In the longer term, in both patients, the gastric tube interpositions appeared to function well and there was no evidence of gastro-oesophageal reflux disease, delayed gastric emptying or troublesome indigestion. Our third patient, who had lifelong severe reflux symptoms, was eating normally three months after the operation with no need for antacid medication. We therefore conclude that laparoscopic Ivor-Lewis oesophagogastrectomy with Roux-en-Y bypass is a more complex reconstruction with added risks but may in the long term result in better overall outcomes and satisfaction for patients, particularly those with benign disease.
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Affiliation(s)
| | - E Forbat
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - A Botha
- Guy's and St Thomas' NHS Foundation Trust , UK
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Lee HH, Kim JJ. Benign Disease of the Stomach. J Gastric Cancer 2015; 15:75-6. [PMID: 26161280 PMCID: PMC4496444 DOI: 10.5230/jgc.2015.15.2.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 11/20/2022] Open
Affiliation(s)
- Han Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Jo Kim
- Division of Gastrointestinal Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Nadaleto BF, Herbella FAM, Patti MG. Gastroesophageal reflux disease in the obese: Pathophysiology and treatment. Surgery 2015; 159:475-86. [PMID: 26054318 DOI: 10.1016/j.surg.2015.04.034] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/07/2015] [Accepted: 04/28/2015] [Indexed: 12/12/2022]
Abstract
Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.
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Affiliation(s)
- Barbara F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
| | - Marco G Patti
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL
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EAES recommendations for the management of gastroesophageal reflux disease. Surg Endosc 2014; 28:1753-73. [PMID: 24789125 DOI: 10.1007/s00464-014-3431-z] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.
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Laparoscopic treatment of obese patients with gastroesophageal reflux disease and Barrett's esophagus: a prospective study. Obes Surg 2012; 22:764-72. [PMID: 22392129 DOI: 10.1007/s11695-011-0531-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients. METHODS In this prospective study, we evaluate the postoperative results after three different procedures--calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)--among obese patients. RESULTS In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagitis was observed in 15% and 20.2% of them, respectively. Patients with LSBE were submitted to FVDGRYGJ or LRRYGBP which significantly improved their symptoms and erosive esophagitis. No modifications of LESP were observed in patients who submitted to LRRYGBP before or after the operation. Acid reflux diminished after the three types of surgery were employed. Patients who submitted to LRRYGBP presented a significant reduction of BMI from 41.5 ± 4.3 to 25.7 ± 1.3 kg/m(2) after 12 months. CONCLUSIONS Among patients with LSBE, FVDGRYGJ presents very good results in terms of improving GERD and Barrett's esophagus, but the reduction of weight is limited. LRRYGBP improves GERD disease and Barrett's esophagus with proven reduction in body weight and BMI, thus becoming the procedure of choice for obese patients.
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Laparoscopic surgical treatment for patients with short- and long-segment Barrett's esophagus: which technique in which patient? Int Surg 2011; 96:95-103. [PMID: 22026298 DOI: 10.9738/cc29.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Laparoscopic antireflux surgery is very successful in patients with short-segment Barrett's esophagus (BE), but in patients with long-segment BE, the results remain in discussion. In these patients, during the open era of surgery, we performed acid suppression + duodenal diversion procedures added to the antireflux procedure (fundoplication + vagotomy + antrectomy + Roux-en-Y gastrojejunostomy) to obtain better results at long-term follow-up. The aim of this prospective study is to present the results of 3 to 5 years' follow-up in patients with short-segment and long-segment or complicated BE (ulcer or stricture) who underwent fundoplication or the acid suppression-duodenal diversion technique, both performed by a laparoscopic approach. One hundred eight patients with histologically confirmed BE were included: 58 patients with short-segment BE, and 50 with long-segment BE, 28 of whom had complications associated with severe erosive esophagitis, ulcer, or stricture. After surgery, among patients treated with fundoplication with cardia calibration, endoscopic erosive esophagitis was observed in 6.9% of patients with short-segment BE, while 50% of patients with long-segment BE presented with positive acid reflux, persistence of endoscopic esophagitis with intestinal metaplasia, and progression to dysplasia (in 5% of cases; P = 0.000). On the contrary, after acid suppression-duodenal diversion surgery in patients with long-segment BE, more than 95.6% presented with successful results regarding recurrent symptoms and endoscopic regression of esophagitis. Regression of intestinal metaplasia to the cardiac mucosa was observed in 56.9% of patients with short-segment BE who underwent fundoplication and in 61% of those with long-segment BE treated with the acid suppression-duodenal diversion procedure. Patients with long-segment BE who experienced fundoplication alone presented no regression of intestinal metaplasia; on the contrary, progression to dysplasia was observed in 1 case (P = 0.049). Patients with short-segment BE can be successfully treated with fundoplication, but for patients with long-segment BE, we suggest performance of fundoplication plus an acid suppression-duodenal diversion procedure.
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Makris KI, Panwar A, Willer BL, Ali A, Sramek KL, Lee TH, Mittal SK. The role of short-limb Roux-en-Y reconstruction for failed antireflux surgery: a single-center 5-year experience. Surg Endosc 2011; 26:1279-86. [DOI: 10.1007/s00464-011-2026-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 10/11/2011] [Indexed: 01/08/2023]
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Farnesoid X receptor protects human and murine gastric epithelial cells against inflammation-induced damage. Biochem J 2011; 438:315-23. [PMID: 21619550 DOI: 10.1042/bj20102096] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Bile acids from duodenogastric reflux promote inflammation and increase the risk for gastro-oesophageal cancers. FXR (farnesoid X receptor/NR1H4) is a transcription factor regulated by bile acids such as CDCA (chenodeoxycholic acid). FXR protects the liver and the intestinal tract against bile acid overload; however, a functional role for FXR in the stomach has not been described. We detected FXR expression in the normal human stomach and in GC (gastric cancer). FXR mRNA and protein were also present in the human GC cell lines MKN45 and SNU5, but not in the AGS cell line. Transfection of FXR into AGS cells protected against TNFα (tumour necrosis factor α)-induced cell damage. We identified K13 (keratin 13), an anti-apoptotic protein of desmosomes, as a novel CDCA-regulated FXR-target gene. FXR bound to a conserved regulatory element in the proximal human K13 promoter. Gastric expression of K13 mRNA was increased in an FXR-dependent manner by a chow diet enriched with 1% (w/w) CDCA and by indomethacin (35 mg/kg of body weight intraperitoneal) in C57BL/6 mice. FXR-deficient mice were more susceptible to indomethacin-induced gastric ulceration than their WT (wild-type) littermates. These results suggest that FXR increases the resistance of human and murine gastric epithelial cells to inflammation-mediated damage and may thus participate in the development of GC.
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Fujimura T, Oyama K, Sasaki S, Nishijima K, Miyashita T, Ohta T, Koichi M, Takanori H. Inflammation-related carcinogenesis and prevention in esophageal adenocarcinoma using rat duodenoesophageal reflux models. Cancers (Basel) 2011; 3:3206-24. [PMID: 24212953 PMCID: PMC3759194 DOI: 10.3390/cancers3033206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 08/02/2011] [Accepted: 08/04/2011] [Indexed: 12/30/2022] Open
Abstract
Development from chronic inflammation to Barrett's adenocarcinoma is known as one of the inflammation-related carcinogenesis routes. Gastroesophageal reflux disease induces regurgitant esophagitis, and esophageal mucosa is usually regenerated by squamous epithelium, but sometimes and somewhere replaced with metaplastic columnar epithelium. Specialized columnar epithelium, so-called Barrett's epithelium (BE), is a risk factor for dysplasia and adenocarcinoma in esophagus. Several experiments using rodent model inducing duodenogastroesophageal reflux or duodenoesophageal reflux revealed that columnar epithelium, first emerging at the proliferative zone, progresses to dysplasia and finally adenocarcinoma, and exogenous carcinogen is not necessary for cancer development. It is demonstrated that duodenal juice rather than gastric juice is essential to develop esophageal adenocarcinoma in not only rodent experiments, but also clinical studies. Antireflux surgery and chemoprevention by proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective cyclooxygenase-2 inhibitors, green tea, retinoic acid and thioproline showed preventive effects on the development of Barrett's adenocarcinoma in rodent models, but it remains controversial whether antireflux surgery could regress BE and prevent esophageal cancer in clinical observation. The Chemoprevention for Barrett's Esophagus Trial (CBET), a phase IIb, multicenter, randomized, double-masked study using celecoxib in patients with Barrett's dysplasia failed to prove to prevent progression of dysplasia to cancer. The AspECT (Aspirin Esomeprazole Chemoprevention Trial), a large multicenter phase III randomized trial to evaluate the effects of esomeprazole and/or aspirin on the rate of progression to high-grade dysplasia or adenocarcinoma in patients with BE is now ongoing.
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Affiliation(s)
- Takashi Fujimura
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +81-76-265-2362; Fax: +81-76-234-4260
| | - Katsunobu Oyama
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Shozo Sasaki
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Koji Nishijima
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Tomoharu Miyashita
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Tetsuo Ohta
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Miwa Koichi
- Houju Memorial Hospital, Nomi, Japan, 11-71 Midorigaoka, Nomi, Ishikawa 923-1226, Japan; E-Mail:
| | - Hattori Takanori
- Division of Molecular and Diagnostic Pathology, Shiga University of Medical Science, Otsu, Japan, Seta Tsukinowa-cho, Otsu, Shiga 520-2192, Japan; E-Mail:
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Kauttu TME, Rantanen TK, Sihvo EI, Räsänen JV, Puolakkainen P, Salo JA. Esophageal adenocarcinoma arising after antireflux surgery: a population-based analysis. Eur J Cardiothorac Surg 2011; 40:1450-4; discussion 1454. [PMID: 21546258 DOI: 10.1016/j.ejcts.2011.02.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Fundoplication is widely used to treat gastroesophageal reflux disease (GERD). Whether it diminishes the development of esophageal adenocarcinoma (EAC) is, however, controversial. Our aim was to define, at the national level in Finland, frequency and predisposing factors for post-fundoplication EAC. METHODS For this population-based study from 1980 to 2006, Finland's administrative databases provided preliminary data. Analyses of EAC patient records (N = 1035) led us to include those with preceding antireflux surgery. Conservatively treated patients were not analyzed. The EAC incidence in patients with antireflux surgery was compared with that in the general population (1987-2006) by means of standardized incidence ratio (SIR). RESULTS A total of 53 (5.1%) EAC patients had undergone antireflux surgery. Of these patients with male predominance (74%), preoperatively 41 (77%) had developed endoscopic esophagitis, 40 (75%) hiatal hernia, 24 (45%) Barrett's esophagus (BE), nine (17%) ulcer in the esophagus or gastroesophageal junction, and three (6%) stricture. Postoperatively, histologically confirmed BE was present in 42 (79%). Antireflux surgery had preceded EAC at a mean interval of 10.1 years (range 0.5-25.6 years). This interval was significantly (p=0.02) shorter in patients with long-term functioning fundoplication (n = 15; 30%) at EAC diagnosis (6.4 years, range 0.5-15.2 years) than in those (n = 22, 44%) with failure (11.2 years, range 4.0-24.3 years). Overall, the SIR for EAC after antireflux surgery (1987-2006) was 9.21. CONCLUSIONS Intention-to-treat GERD with antireflux surgery does not prevent EAC. It often develops more than 5 years postoperatively, also in the patients with a good antireflux barrier. Only one-third of the patients had, however, a functioning fundoplication. Preoperative BE and endoscopic esophagitis may be risk factors. Prospective, long-term, randomized studies in experienced centers may reveal the definite effect of antireflux surgery on EAC development.
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Affiliation(s)
- Tuuli M E Kauttu
- Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Wu YC, Tang YB, Chen W, Lai CS, Chen HC. Combination of a free jejunal flap and a Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: A case report. Microsurgery 2011; 31:331-4. [DOI: 10.1002/micr.20873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Revised: 11/22/2010] [Accepted: 11/29/2010] [Indexed: 11/10/2022]
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DeMeester SR. Reflux, Barrett's, and adenocarcinoma of the esophagus: can we disrupt the pathway? J Gastrointest Surg 2010; 14:941-5. [PMID: 20094815 DOI: 10.1007/s11605-009-1146-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 12/14/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Steven R DeMeester
- Department of Surgery, The University of Southern California, Keck School of Medicine, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033, USA.
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Braghetto I, Korn O, Cardemil G, Coddou E, Valladares H, Henriquez A. Inversed Y cardioplasty plus a truncal vagotomy-antrectomy and a Roux-en-Y gastrojejunostomy performed in patients with stricture of the esophagogastric junction after a failed cardiomyotomy or endoscopic procedure in patients with achalasia of the esophagus. Dis Esophagus 2010; 23:208-15. [PMID: 19903194 DOI: 10.1111/j.1442-2050.2009.01021.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic anterior cardiomyotomy in addition to anterior Dor's fundoplication is the procedure of choice for achalasia of the esophagus with approximately 95% success rate. Redo cardiomyotomy is complicated and associated with rerecurrence of dysphagia. Twelve patients with failed redo myotomy were clinically evaluated with radiology, endoscopy, and manometry in whom achalasia type III or IV was confirmed. We propose as treatment for these selected cases an inversed Y cardioplasty + truncal vagotomy, a partial distal gastrectomy and Roux-en-Y gastrojejunostomy in order to facilitate esophageal emptying and avoid the appearance of postoperative gastroesophageal reflux as a side effect of this procedure. One patient was reoperated on in order to enlarge the cardioplasty. Disappearance of dysphagia was confirmed in all patients. Three patients presented reflux symptoms and were treated with 20 mg of Omeprazole 20 twice/day. No food retention, erosive esophagitis, or Barrett's esophagus were observed. The mean resting pressure decreased from 24.9 +/- 8.5 mm Hg to 7.5 +/- 2.5 mm Hg (P = 0.0001). Furthermore, esophageal diameter decreased significantly after a 5-year follow-up. This procedure could be an option for treating patients in which repeated Heller operations have failed.
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Affiliation(s)
- I Braghetto
- Department of Surgery, University of Chile, Santiago, Chile.
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Makris KI, Lee T, Mittal SK. Roux-en-Y reconstruction for failed fundoplication. J Gastrointest Surg 2009; 13:2226-32. [PMID: 19727973 DOI: 10.1007/s11605-009-0994-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 08/10/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Redo fundoplication has acceptable outcomes in patients with failed previous fundoplications. However, a subset of patients require Roux-en-Y (RNY) reconstruction for symptom relief. AIM The aim of this study was to demonstrate safety and efficacy of RNY reconstruction for failed fundoplications. METHOD Retrospective review of data on patients who underwent short-limb RNY gastrojejunostomy (GJ) or esophagojejunostomy (EJ) between the years 2005 and 2007 was performed. RESULTS Twenty-two patients underwent RNY reconstructions. Fourteen (64%) patients had one, six (27%) patients had two, and 2 (9%) patients had three previous anti-reflux procedures. RNY GJ was performed in 18 patients and EJ in four patients. Gastrectomy was performed in 13 of these patients. Seven patients (32%) had ten major or minor complications within the 30-day postoperative period, without any mortality observed. At a mean follow-up of 23 months, completed in 21 of these patients (95%), the average heartburn score was 0.38 (range, 0-2). The average regurgitation score was 0.23 (range, 0 to2) and the average dysphagia score was 0.7 (range, 0-2). The mean postoperative BMI was 25.4 compared to a preoperative BMI of 31. CONCLUSION RNY reconstruction with GJ or EJ for failed anti-reflux procedures is a safe, valid surgical option in difficult situations, where a redo fundoplication is either non-feasible or expected to fail. However, it is associated with higher morbidity.
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Affiliation(s)
- Konstantinos I Makris
- Department of Surgery, Creighton University Medical Center, 601 North 30th Street, Suite 3700, Omaha, NE 68131, USA
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D'Journo XB, Martin J, Gaboury L, Ferraro P, Duranceau A. Roux-en-Y Diversion for Intractable Reflux After Esophagectomy. Ann Thorac Surg 2008; 86:1646-52. [DOI: 10.1016/j.athoracsur.2008.06.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 06/17/2008] [Accepted: 06/18/2008] [Indexed: 02/08/2023]
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Behavior of the infection by Helicobacter pylori of the gastric remnant after subtotal gastrectomy and Roux-en-Y anastomosis for benign diseases. J Gastrointest Surg 2008; 12:1508-11. [PMID: 18612708 DOI: 10.1007/s11605-008-0571-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 06/04/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Reinfection by Helicobacter pylori of the gastric remnant after partial gastrectomy has been implicated in the development of gastric cancer at the gastric stump. OBJECTIVE The aim of this study is to determine the rate of infection by H. pylori after partial gastrectomy and Roux-en-Y anastomosis for benign disease. MATERIALS AND METHODS A total of 79 patients with long segment Barrett's esophagus were submitted to vagotomy, anti-reflux surgery, two thirds distal gastrectomy, and Roux-en-Y anastomosis 70 cm long. In all preoperative biopsy samples were taken from the antrum. After surgery, four endoscopic studies were performed in different periods of time. Mean follow-up was 98 months after operation (60-240). RESULTS Three groups of patients were identified: (a) group 1, 43 patients (54%) who had no preoperative infection by H. pylori and remained so late after surgery; (b) group 2, 21 patients (27%) who had no preoperative infection by H. pylori but presented infection of the gastric remnant that increased parallel to the length of follow-up; (c) group 3, 15 patients (19%) who presented infection by H. pylori before surgery. From them, 11 showed reinfection of the gastric remnant, while four patients had no reinfection. CONCLUSION After partial gastrectomy and Roux-en-Y anastomosis for benign disease, there are three different patterns of behavior regarding reinfection or not by H. pylori. A total of 41% of patients presented H. pylori reinfection at the gastric remnant after Roux-en-Y anastomosis, which increased parallel to the length of follow-up.
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Awais O, Luketich JD, Tam J, Irshad K, Schuchert MJ, Landreneau RJ, Pennathur A. Roux-en-Y near esophagojejunostomy for intractable gastroesophageal reflux after antireflux surgery. Ann Thorac Surg 2008; 85:1954-9; discussion 1959-61. [PMID: 18498802 DOI: 10.1016/j.athoracsur.2008.01.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 01/22/2008] [Accepted: 01/23/2008] [Indexed: 01/27/2023]
Abstract
BACKGROUND Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery. METHODS Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions. RESULTS There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001). CONCLUSIONS The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.
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Affiliation(s)
- Omar Awais
- The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Koak Y, Davies SE, Winslet M. Effect of Roux-en-Y surgery and medical intervention on Barrett's-type changes: an in vivo model. Dis Esophagus 2008; 21:751-6. [PMID: 18522638 DOI: 10.1111/j.1442-2050.2008.00839.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In animal models, mixed acid and bile reflux into lower esophagus induces histological changes comparable to Barrett's metaplasia (BM) and neoplasia. The aim of this study was to compare the effects of Roux-en-Y (REY) surgery and medical therapy on BM in animals before the development of neoplasia. Vagus preserving esophagojejunostomy operation was performed on Sprague-Dawley rats to achieve gastroduodenal reflux (GDR) into the esophagus in 30 animals. After 3 months, changes were reversed in 10 animals (Group REY) by REY operation, 10 animals (Group proton pump inhibitor [PPI]) were given PPI during the postoperative period, and 10 animals (Group GDR) did not have further intervention. At 4 months, histological examination of the lower esophagus was performed by an experienced pathologist. Physiological parameters were also analyzed in all animals preoperatively and at 4 months postoperatively. The length of columnar mucosa, degree of acute inflammation, degree of metaplasia, and composite BM score were significantly reduced by REY surgery compared with medical therapy and with control (columnar mucosa in cm [mean +/- standard error of the mean] Group REY 0.44 +/- 0.06, Group PPI 0.92 +/- 0.08, P < 0.001/Group GDR 1.17 +/- 0.31, P < 0.03). There was no neoplasia seen in any specimen. At 4 months, postoperatively controls Group REY surgery showed significantly more normalization of physiological parameters to preoperative levels than Group PPI (P < 0.05). REY surgery is potentially more beneficial than medical therapy in reversing the histological and biochemical changes of Barrett's esophagus due to GDR.
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Affiliation(s)
- Y Koak
- Department of Surgery, Royal Free and University College School of Medicine, London, UK.
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Houghton SG, Romero Y, Sarr MG. Effect of Roux-en-Y gastric bypass in obese patients with Barrett's esophagus: attempts to eliminate duodenogastric reflux. Surg Obes Relat Dis 2007; 4:1-4; discussion 4-5. [PMID: 18069070 DOI: 10.1016/j.soard.2007.10.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 09/05/2007] [Accepted: 10/09/2007] [Indexed: 01/26/2023]
Abstract
BACKGROUND To assess the effect of Roux-en-Y gastric bypass (RYGB) at a tertiary referral Center of Excellence for bariatric surgery on the length and presence of dysplasia in morbidly obese patients with Barrett's esophagus (BE). Esophageal reflux of gastroduodenal contents (acid, bile) contributes to the development of BE and progression in the dysplasia-carcinoma sequence. Obese patients have a high prevalence of gastroesophageal reflux and might be at an increased risk of developing BE and esophageal adenocarcinoma. The effect of eliminating duodenogastroesophageal reflux on BE is not known. METHODS We performed a retrospective review of all patients with pre-existing, biopsy-proven, long-segment (>3 cm) BE undergoing RYGB at our institution. Only patients with >1 year of endoscopic, biopsy-controlled follow-up (mean 34 mo) were included. RESULTS Five patients (3 men and 2 women) were identified. The mean +/- standard error of the mean preoperative length of BE was 6 +/- 2 cm; 2 patients had low-grade dysplasia and 1 indeterminate dysplasia. At the postoperative follow-up (>1 yr) examinations, the length of BE had decreased in 4 patients; the overall length was 2 +/- 1 cm; and only 1 patient had dysplasia. All patients experienced a decrease in the length of BE (n = 4), complete disappearance of BE (n = 2), or improvement in the degree of dysplasia (n = 3). The body mass index had decreased from 43 +/- 4 kg/m(2) to 33 +/- 3 kg/m(2), and all experienced subjective improvement in reflux symptoms postoperatively. RYGB resulted in complete or partial regression of BE in 4 of 5 patients and improvement in reflux symptoms in all. CONCLUSION Our results suggest that RYGB might be the procedure of choice in morbidly obese patients with BE requiring surgical treatment for gastroesophageal reflux disease.
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Affiliation(s)
- Scott G Houghton
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Lenglinger J, Eisler M, Riegler M. Ablation and antireflux surgery for regression of Barrett's oesophagus. Aliment Pharmacol Ther 2007; 26:509-10; author reply 510-1. [PMID: 17635386 DOI: 10.1111/j.1365-2036.2007.03342.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Abstract
PURPOSE OF REVIEW Barrett's esophagus is a complication of chronic gastroesophageal reflux that results in the replacement of normal stratified squamous epithelium in the distal esophagus by metaplastic columnar mucosa and it carries a 30-fold to 125-fold risk of progression to esophageal adenocarcinoma. RECENT FINDINGS Laparoscopic antireflux surgery has proved durable and effective in treating reflux and reflux-related symptoms in patients with Barrett's esophagus. Recent studies have also focused on the histological changes induced in Barrett's epithelium by antireflux surgery. This article reviews the current literature, analysing the impact of antireflux surgery on both the clinical and the histopathological outcomes. SUMMARY Recent studies have disproved the widely held assumption that, once established, Barrett's esophagus does not change. Antireflux surgery can achieve a regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's esophagus and may thus alter the natural history of the disease.
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Affiliation(s)
- Giovanni Zaninotto
- Department of General Surgery, S. Giovanni e Paolo Hospital, Venice, and Department of General Surgery & Organ Transplantation, University of Padova, Italy.
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Lenglinger J, Eisler M, Riegler M. Surgery versus proton pump inhibitor: fair to compare? Ann Surg 2007; 245:338. [PMID: 17245195 PMCID: PMC1876994 DOI: 10.1097/01.sla.0000253073.43168.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH. Gastrectomy as a remedial operation for failed fundoplication. J Gastrointest Surg 2007; 11:29-35. [PMID: 17390183 DOI: 10.1007/s11605-006-0048-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997-2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients' overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.
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Affiliation(s)
- Valerie A Williams
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
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Mabrut JY, Collard JM, Baulieux J. Le reflux biliaire duodéno-gastrique et gastro-œsophagien. ACTA ACUST UNITED AC 2006; 143:355-65. [PMID: 17285081 DOI: 10.1016/s0021-7697(06)73717-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.
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Affiliation(s)
- J Y Mabrut
- Service de Chirurgie Générale, Digestive et de Transplantation Hépatique, Hôpital de la Croix-Rousse - Lyon.
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Lenglinger J, Eisler M, Riegler M. Evidence for chief cells within columnar-lined esophagus? Surgery 2006; 140:479. [PMID: 16934615 DOI: 10.1016/j.surg.2006.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 01/23/2006] [Indexed: 11/22/2022]
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Abstract
The aim of this study was to review the literature about the effect of antireflux surgery on the metaplasia-dysplasia-adenocarcinoma sequence in patients with Barrett's oesophagus. Antireflux operations (by laparotomy or laparoscopy) can alter the natural history of Barrett's oesophagus, allowing disease stabilization in a substantial proportion of patients without high grade dysplasia at time of surgery. It also may induce complete or partial regression of Barrett's epithelium, especially for short segment of Barrett's oesophagus, but in unpredictable manner. While regression of low-grade dysplasia is commonly observed, histologic progression is rarely observed after effective antireflux surgery. However, ineffective antireflux surgery expose to histologic progression to high-grade dysplasia or adenocarcinoma. These data support the need for a long-term clinical, endoscopic, and histologic follow-up program after antireflux surgery in patients with Barrett's oesophagus.
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Affiliation(s)
- J-Y Mabrut
- Service de Chirurgie Générale, Digestive et de la Transplantation Hépatique, Hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
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36
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Csendes A, Burgos AM, Smok G, Burdiles P, Henriquez A. Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg 2006; 10:259-64. [PMID: 16455459 DOI: 10.1016/j.gassur.2005.06.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Revised: 06/09/2005] [Accepted: 06/13/2005] [Indexed: 01/31/2023]
Abstract
Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett's esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m(2) to 29.4 kg/m(2) 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.
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Affiliation(s)
- Attila Csendes
- Department of Surgery, Clinical Hospital University of Chile, Santos Dumont #999, Santiago, Chile.
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