Barrett's esophagus: the role of laparoscopic fundoplication

Giant diaphragmatic hernia surgical treatment by laparoscopic repair: a case report

Diaphragmatic hernias occur in up to 10%-50% of the general population. Treatment of hiatal hernias depends on the type of hernia and the severity of the symptoms. We report the case of a 52-year-old woman with no significant history who presented for 1 year with non-specific chest pain, dyspnea, dysphagia, and heartburn. A thoracoabdominal tomography with contrast was performed, showing a diaphragmatic hernia containing the stomach, portions of the duodenum, pancreas, small intestine, and colon with a sac of up to 20 cm, which was successfully repaired laparoscopically.

Proton Pump Inhibitors, Associated Complications, and Alternative Therapies: A Shifting Risk Benefit Ratio

OBJECTIVE

Our goal was to compile the most recent and accurate data on the side effects of proton pump inhibitors (PPI). We also compared the efficacy of PPI to the efficacy of different surgical options for acid reflux control.

BACKGROUND

Proton pump inhibitors are the primary therapy for chronic control of gastroesophageal reflux disease (GERD), but newer studies demonstrate deleterious side effects. Collating this information and contrasting it with surgical therapy for GERD provides evidence for possible practice changes in treatment.

METHODS

A literature search utilizing PubMed was performed evaluating for PPI and anti-reflux surgery (ARS), focusing on articles that reflected information regarding the usage and efficacy of symptom control of both PPI and ARS. Search terms included "ARS, fundoplication, MSA, acute interstitial nephritis, acute kidney injury, chronic kidney disease, meta-analysis, PPI, H₂ blocker, cardiovascular risk, and gut dysbiosis." We evaluated 271 articles by title, abstract, and data for relevance and included 70.

RESULTS

Long-term control of GERD with PPI may have a greater than expected side effect profile than initially thought. Surgical options may provide greater symptom control than PPI without the side effects of long-term medical therapy.

CONCLUSIONS

Anti-reflux control can be safely achieved with either PPI or surgical options; however, the long-term side effects noted in the review such as increased risk of cardiovascular events, renal disease, and gut dysbiosis may suggest surgical anti-reflux control as a better long-term option.

Esophagus and Gastrointestinal Junction Tumors

Esophageal squamous cell carcinoma and adenocarcinoma account for 95% of all esophageal malignancies. The rates of esophageal adenocarcinoma have increased in Western countries, making it the predominant type of esophageal cancer. Treatment of both types of cancer has transformed to a more minimally invasive approach, with endoscopic methods being used for superficial cancers and more frequent use of video-assisted and laparoscopic modalities for locally advanced tumors. The current National Comprehensive Cancer Network guidelines advocate a trimodal approach to treatment, with neoadjuvant chemoradiation and surgery for locally advanced cancers.

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Evaluation and Management of Premalignant Conditions of the Esophagus: A Systematic Survey of International Guidelines

Esophageal cancer represents one of the most lethal forms of malignancy. The growing incidence of esophageal adenocarcinoma represents an emerging public health concern. This review article summarizes current diagnostic, management, and therapeutic practices of premalignant conditions of the esophagus including Barrett's esophagus, tylosis, granular cell tumors, achalasia, and the ingestion of caustic substances. Our report provides clinicians and academics with a global clinical perspective regarding presentation, surveillance guidelines, and therapeutic management of these esophageal conditions.

Minimally Invasive Fundoplication Is Safe and Effective in Patients With Severe Esophageal Hypomotility

OBJECTIVE

Fundoplication is used to treat refractory gastroesophageal reflux disease (GERD). A subset of patients has coexisting esophageal dysmotility, including aperistalsis or hypoperistalsis. These patients may be at increased risk of dysphagia after fundoplication. To evaluate the outcomes of minimally invasive fundoplication (MIF) in patients with GERD and esophageal hypomotility.

METHODS

Retrospective review of all patients who underwent MIF and had severe esophageal hypomotility from January 2003 to June 2013. Patients underwent both pH testing and high-resolution esophageal manometry before surgery, in addition to symptom assessment before and after surgery. Severe esophageal hypomotility was defined as mean distal amplitude of contraction of less than 30 mm Hg and liquid bolus clearance of less than 50%.

RESULTS

Thirty-four patients with GERD and esophageal hypomotility were included. By manometry, 38% had scleroderma-like esophagus and the other 62% had ineffective peristalsis. Ten patients (29%) had systemic scleroderma. Fundoplications performed (34 laparoscopically and 4 robotically) included Toupet (30), Dor (2), and Nissen (2). All patients tolerated oral feeding at a median of 1 day. One patient required surgical revision at 4 months postoperatively. Mean follow-up was 36 weeks, at which time 41% were asymptomatic and 56% had reduced symptoms. Persistent dysphagia was noted in four patients (11.7%) and was successfully treated with endoscopic dilation.

CONCLUSIONS

Minimally invasive fundoplication is both safe and effective in treating patients with severe GERD and concomitant esophageal hypomotility. Those with postoperative dysphagia are successfully managed by endoscopic treatments.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Acid suppression and surgical therapy for Barrett's oesophagus

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.

Incidence of esophageal adenocarcinoma in Barrett's esophagus with low-grade dysplasia: a systematic review and meta-analysis

BACKGROUND

The natural history of low-grade dysplasia (LGD) in patients with Barrett's esophagus (BE) is unclear.

OBJECTIVE

We performed a systematic review and meta-analysis of studies that reported the incidence of esophageal adenocarcinoma (EAC) and/or high-grade dysplasia (HGD) among patients with BE with LGD.

DESIGN

Systematic review and meta-analysis of cohort studies.

PATIENTS

Patients with BE-LGD, with mean cohort follow-up ≥ 2 years.

MAIN OUTCOME MEASUREMENTS

Pooled incidence rates with 95% confidence intervals (CI) of EAC and/or BE-HGD.

RESULTS

We identified 24 studies reporting on 2694 patients with BE-LGD, with 119 cases of EAC. Pooled annual incidence rates of EAC alone and EAC and/or HGD in patients with BE-LGD were 0.54% (95% CI, 0.32-0.76; 24 studies) and 1.73% (95% CI, 0.99-2.47; 17 studies). The results were stable across study setting and location and in high-quality studies. Substantial heterogeneity was observed, which could be explained by stratifying based on LGD/BE ratio as a surrogate for quality of pathology; the pooled annual incidence rates of EAC were 0.76% (95% CI, 0.44-1.09; 14 studies) for LGD/BE ratio <0.15 and 0.32% (95% CI, 0.07-0.58; 10 studies) for LGD/BE ratio >0.15. The annual rate of mortality not related to esophageal disease in patients with BE-LGD was 4.7% (95% CI, 3.2-6.2; 4 studies).

LIMITATIONS

Substantial heterogeneity was observed in the overall analysis.

CONCLUSION

The incidence of EAC among patients with BE-LGD is 0.54% annually. The LGD/BE ratio appears to explain the variation observed in the reported incidence of EAC in different cohorts. Conditions not related to esophageal disease are a major cause of mortality in patients with BE-LGD, although additional studies are warranted.

EAES recommendations for the management of gastroesophageal reflux disease

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.

Two-year subjective, objective, quality of life, and endoscopic follow-up after laparoscopic Nissen-Rossetti in patients with columnar-lined esophagus

INTRODUCTION

Barrett esophagus (BE) is a complication of gastroesophageal reflux disease. We wish to determine the effects of surgery on the histology of the esophageal mucosa and evaluate Quality of Life.

MATERIALS AND METHODS

Twenty-seven patients with columnar-lined esophagus (CLE) metaplasia underwent laparoscopic Nissen-Rossetti fundoplication. Patients were submitted to close follow-up.

RESULTS

One patient voluntarily left follow-up after surgery. CLE was still present in 18 patients (66.6%); no patient developed dysplasia or esophageal adenocarcinoma. Two patients with gastric metaplasia and 1 patient with intestinal metaplasia had regression at 12 and 24 months after surgery (11.1%). DeMeester and Johnson score decreased from 38.69 (SD ± 51.44) to 11.99 (SD ± 18.08) at 6 months, 12.69 (SD ± 12.91) at 12 months, and it was 11.38 (SD ± 6.43) at 24 months. Preoperative gastroesophageal reflux disease-health related quality of life was 19.90 (SD ± 18.54), 9.80 (SD ± 8.77) at 6 months, 9.57 (SD ± 9.14) at 12 months, and 11.53 (SD ± 6.48) at 24 months. Short form-36 measurement showed significant improvement.

CONCLUSIONS

Management of CLE requires multidisciplinary approach. Medical therapy does not prevent biliary reflux into the esophagus. Surgical therapy is effective and long lasting. It should be performed by experienced surgical teams.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

The effects of laparoscopic Nissen fundoplication on Barrett's esophagus: long-term results

OBJECTIVE

The aim of our study was to conduct a retrospective investigation of the efficacy of laparoscopic Nissen fundoplication in patients with Barrett's esophagus.

MATERIAL AND METHODS

A total of 78 patients with Barrett's esophagus underwent surgery. Patients were divided into three groups on the basis of the preoperative endoscopic biopsies: a non-intestinal group (n = 63) with fundic or cardiac metaplasia, an intestinal group (n = 18) with intestinal metaplasia, and a dysplastic group (n = 7) with low-grade dysplasia. Clinical follow-up was available in the case of 64 patients at a mean of 42 ± 16.9 months after surgery.

RESULTS

Check-up examination revealed total regression of Barrett's metaplasia in 10 patients. Partial regression was seen in 9 cases, no further progression in 34 patients, and progression into cardiac or intestinal metaplasia in 11 patients. No cases of dysplastic or malignant transformation were registered. Where we observed the regression of BE, among the postoperative functional examinations results of manometry (pressure of lower esophageal sphincter) and pH-metry were significantly better compared with those groups where no changes occurred in BE, or progression of BE was found. Discussion. Our results highlight the importance of the cases of fundic and cardiac metaplasia, which can also transform into intestinal metaplasia.

CONCLUSIONS

Antireflux surgery can appropriately control the reflux disease in a majority of the patients who had unsuccessful medical treatment, and it may inhibit the progression and induce the regression of Barrett's metaplasia in a significant proportion of these patients.

Laparoscopic surgical treatment for patients with short- and long-segment Barrett's esophagus: which technique in which patient?

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.

Role of acid suppression in the development and progression of dysplasia in patients with Barrett's esophagus

Barrett's esophagus (BE) usually develops in patients with gastroesophageal reflux disease and therefore it has been suggested that esophageal acid exposure plays an import role in the initiation of BE and its progression towards esophageal adenocarcinoma (EAC). The mechanisms whereby acid exposure causes BE are not completely revealed and the potential role of esophageal acid exposure in carcinogenesis is unclear as well. Since acid exposure is thought to play an important role in the progression of BE, therapies aimed at preventing the development of EAC have primarily focused on pharmacological and surgical acid suppression. In clinical practice, acid suppression is effective in relieving reflux symptoms and decreases esophageal acid exposure in most patients. However, in some individuals, pathological acid exposure persists and these patients continue to be at risk for developing dysplasia or EAC. To date, published trials suggest that acid suppression is able to prevent the development and progression of dysplasia in patients with BE, but definite and compelling proof is still lacking. This article reviews the mechanisms of acid-induced carcinogenesis in BE and the role of acid suppression in the prevention of neoplastic progression.

Impact of laparoscopic Nissen fundoplication on non-complicated Barrett's esophagus

BACKGROUND/AIM

Laparoscopic fundoplication can alter the natural course of Barrett's esophagus (BE). This study was undertaken to assess this role in patients with non-complicated BE.

MATERIALS AND METHODS

From October 2004 to October 2009, 43 patients with BE (32 men and 11 women) underwent laparoscopic Nissen fundoplication surgery in the Department of Surgery at Minia University Hospital. The median age of these patients was 46 years (range: 22-68 years). Patients with high-grade dysplasia, invasive cancer, or previous antireflux surgery were excluded. All 43 patients had gastroesophageal reflux symptoms. Heartburn was present in all patients, regurgitation in 41 (95.3%), dysphagia in 8 (18.6%), retrosternal pain in 30 (69.8%), upper gastrointestinal hemorrhage in 6 (13.9%), and respiratory symptoms in 19 (44.2%). Nissen fundoplication was performed in all patients. Thirty-four patients (79.1%) had concomitant hiatal hernia and nine patients (20.9%) had low-grade dysplasia.

RESULTS

The median follow-up period was 25.6 months. There was significant improvement of symptoms after surgery (P<0.05). Eight (18.6%) of those with short-segment BE had total regression and four (9.3%) of those with long-segment BE had a decrease in total length. Among the nine patients with preoperative low-grade dysplasia, dysplasia disappeared in seven, remained unchanged in one, and progressed to in situ adenocarcinoma in one patient.

CONCLUSIONS

laparoscopic fundoplication succeeded in controlling symptoms but had unpredictable effect on dysplasia and regression of BE. Laparoscopic fundoplication does not eliminate the risk of developing esophageal adenocarcinoma and therefore, endoscopic follow-up should be continued in these patients.

Effect of medical and surgical treatment of Barrett’s metaplasia

Barrett’s esophagus (BE) is a change in the esophageal mucosa as a result of long-standing gastroesophageal reflux disease. The importance of BE is that it is the main risk factor for the development of esophageal adenocarcinoma, whose incidence is currently growing faster than any other cancer in the Western world. The aim of this review was to compare the common treatment modalities of BE, with the focus on proton pump inhibitors and operative fundoplication. We performed a literature search on medical and surgical treatment of BE to determine eligible studies for this review. Studies on medical and surgical treatment of BE are discussed with regard to treatment effect on progression and regression of disease. Although there is some evidence for control of reflux with either medical or surgical therapy, there is no definitive evidence that either treatment modality decreases the risk of progression to dysplasia or cancer. Even though there is a trend toward antireflux surgery being superior, there are no definitive studies to prove this.

Radiofrequency ablation for Barrett's esophagus and low-grade dysplasia in combination with an antireflux procedure: a new paradigm

OBJECTIVE

Radiofrequency ablation for Barrett's esophagus in combination with an antireflux procedure has not been widely documented. We report our initial experience with radiofrequency ablation in association with antireflux procedure for Barrett's metaplasia and low-grade dysplasia.

METHODS

A total of 14 patients (10 male and 4 female patients) presented with Barrett's metaplasia (n=11) or low-grade dysplasia (n=3). Median age was 60 years (38-80 years). The severity of Barrett's esophagus was classified by length (in centimeters), appearance (circumferential/noncircumferential), and histology (1, normal; 2, Barrett's metaplasia; and 3, low-grade dysplasia). Radiofrequency ablation was performed with the HALO 360 degrees or 90 degrees systems (BARRX Medical, Sunnyvale, Calif).

RESULTS

Median follow-up was 17 months. The mean number of ablative procedures undertaken was 2.6 (range, 1-6). There was no mortality, but there were 2 perioperative complications after the antireflux procedure (pneumonia, 1; atrial fibrillation, 1). One patient had mild dysphagia requiring a single dilation 2 months after ablation. The mean length of Barrett's esophagus decreased from 6.2 to 1.2 cm after treatment (P=.001). Barrett's grade decreased significantly (P=.003). Before therapy, circumferential Barrett's esophagus was present in 13 patients. At last endoscopy, only 1 patient had circumferential Barrett's esophagus present. The number of radiofrequency ablation treatments was significantly (P < .05) associated with success. All patients receiving 3 or more treatments had complete resolution of Barrett's metaplasia.

CONCLUSIONS

Radiofrequency ablation performed either before or after an antireflux procedure is safe. This approach is effective for reducing or eliminating metaplasia and dysplasia. Long-term studies will be necessary to determine whether this approach can provide durable control of both reflux and Barrett's esophagus.

Treatment of ultralong-segment Barrett's using focal and balloon-based radiofrequency ablation

INTRODUCTION

Endoscopic radiofrequency ablation (ERFA) is being evaluated as definitive treatment for patients with Barrett's esophagus (BE). Guidelines have yet to be developed for the application of this technology to patients with ultralong-segment BE (ULBE, > or = 8 cm). This study reports a single institution's experience with ERFA of ULBE.

METHODS

A retrospective review of patients with ULBE undergoing ERFA from August 2005 to February 2009 was conducted. The entire segment of intestinal metaplasia (IM) was treated at each session using balloon- and/or plate-based devices (BARRX Medical, Inc., Sunnyvale, CA). Retreatments, endoscopic mucosal resection (EMR), dilations, and biopsies were performed based on endoscopic findings. Surveillance was conducted according to standard guidelines.

RESULTS

Twenty-five patients (22 male) with a median age of 66 years [interquartile range (IQR) 57-74 years] were included. The length of BE treated was 10 cm (median; IQR 8-12 cm). Intramucosal carcinoma (IMC) was present in 3 patients, 15 had high-grade dysplasia (HGD), 6 had low-grade dysplasia (LGD), and 1 had IM without dysplasia. Complications for all 25 patients included hemorrhage (n = 1), stricture (n = 2), and nausea and vomiting (n = 2). Time from the initial procedure was such that 15 patients had postablation biopsies at least once. One patient with biopsies elected to undergo esophagectomy. Of these patients, 78.5% (11/14) had complete response (CR; no residual IM), two patients regressed from HGD to IM, and one patient with IMC had residual HGD and was treated with repeat EMR. The number of ablations in this group was 2.5 (median, IQR 2-3) during a median follow-up time of 20.3 months (IQR 10.4-29.2 months).

CONCLUSION

ERFA is safe and feasible in patients with ULBE and can be applied to the entire length of IM during one session. Eradication of BE can be achieved with few repeat ablations and continued, vigilant surveillance.

Radiofrequency ablation of Barrett's esophagus: short-term results

BACKGROUND

The presence of Barrett's esophagus (BE) increases the risk of esophageal cancer. Total regression of BE is uncommon with medication or laparoscopic fundoplication, and endoscopic techniques to obliterate BE have varied results. This study evaluated the early results of a balloon-based catheter radiofrequency ablation (RFA) system in patients with medically refractory reflux symptoms and biopsy-proven BE.

METHODS

The medical records of 27 consecutive patients who underwent RFA for BE from March 2005 through January 2007 were reviewed. Esophagogastroduodenoscopy was performed before ablation to document presence of BE and no cancer and at 8 weeks after the RFA to assess the presence of residual BE.

RESULTS

Mean patient age was 53.6 +/- 12.5 years; 16 (59%) were men. The average length of the Barrett segment treated was 4.6 +/- 4.7 cm. Two patients (7.4%) had low-grade dysplasia. No patient had high-grade dysplasia and cancer. There was no periprocedural morbidity or at follow-up, no postprocedure dysphagia or stricture. In all patients, the BE was completely replaced with normal squamous epithelium. Symptoms regressed in 16 patients (60%) with RFA and proton pump inhibitor therapy. Eleven required an antireflux procedure for persistent symptoms.

CONCLUSIONS

Short-term results show that RFA for BE is safe and achieves 100% replacement of intestinal metaplasia. RFA of BE combined with fundoplication may be offered to patients with BE and medically refractory reflux symptoms. Long-term endoscopic surveillance is needed to determine if the risk of cancer is reduced with this bimodality therapy.

Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience

INTRODUCTION

The long-term management of gastroesophageal reflux in patients with Barrett's esophagus (BE) is not well supported by an evidence-based consensus. We compare treatment outcome in patients with and without BE submitted to standardized laparoscopic antireflux surgery (LARS) or esomeprazole treatment.

METHODS

In the Long-Term Usage of Acid Suppression Versus Antireflux Surgery trial (a European multicenter randomized study), LARS was compared with dose-adjusted esomeprazole (20-40 mg daily). Operative difficulty, complications, symptom outcomes [Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD)], and treatment failure at 3 years and pH testing (after 6 months) are reported.

RESULTS

Of 554 patients with gastroesophageal reflux disease, 60 had BE-28 randomized to esomeprazole and 32 to LARS. Very few BE patients on either treatment strategy (four of 60) experienced treatment failure during the 3-year follow-up. Esophageal pH in BE patients was significantly better controlled after surgical treatment than after esomeprazole (p = 0.002), although mean GSRS and QOLRAD scores were similar for the two therapies at baseline and at 3 years. Although operative difficulty was slightly greater in patients with BE than those without, there was no difference in postoperative complications or level of symptomatic reflux control.

CONCLUSION

In a well-controlled surgical environment, the success of LARS is similar in patients with or without BE and matches optimized medical therapy.

Effect of Roux-en-Y surgery and medical intervention on Barrett's-type changes: an in vivo model

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.

The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review

OBJECTIVE

To determine whether patients with Barrett esophagus who undergo antireflux surgery differ from medically treated patients in incidence of esophageal adenocarcinoma and probability of disease regression/progression.

SUMMARY BACKGROUND DATA

Barrett esophagus is a risk factor for the development of esophageal adenocarcinoma. A question exists as to whether antireflux surgery reduces this risk.

METHODS

Query of PubMed (1966 through October 2005) using predetermined search terms revealed 2011 abstracts, of which 100 full-text articles were reviewed. Twenty-five articles met selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled adults with biopsy-proven Barrett esophagus, specified treatment-type rendered, followed up patients with endoscopic biopsies no less than12 months of instituting therapy, and provided adequate extractable data. The incidence of adenocarcinoma and the proportion of patients developing progression or regression of Barrett esophagus and/or dysplasia were extracted.

RESULTS

In surgical and medical groups, 700 and 996 patients were followed for a total of 2939 and 3711 patient-years, respectively. The incidence rate of esophageal adenocarcinoma was 2.8 (95% confidence interval, 1.2-5.3) per 1000 patient-years among surgically treated patients and 6.3 (3.6-10.1) among medically treated patients (P = 0.034). Heterogeneity in incidence rates in surgically treated patients was observed between controlled studies and case series (P = 0.014). Among controlled studies, incidence rates were 4.8 (1.7-11.1) and 6.5 (2.6-13.8) per 1000 patient-years in surgical and medical patients, respectively (P = 0.320). Probability of progression was 2.9% (1.2-5.5) in surgical patients and 6.8% (2.6-12.1) in medical patients (P = 0.054). Probability of regression was 15.4% (6.1-31.4) in surgical patients and 1.9% (0.4-7.3) in medical patients (P = 0.004).

CONCLUSIONS

Antireflux surgery is associated with regression of Barrett esophagus and/or dysplasia. However, evidence suggesting that surgery reduces the incidence of adenocarcinoma is largely driven by uncontrolled studies.

Surgical options and outcomes in Barrett's esophagus

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.

Does Barrett's esophagus impact outcome after laparoscopic Nissen fundoplication?

BACKGROUND

This study was undertaken to compare patients with gastroesophageal reflux disease (GERD) with or without Barrett's esophagus for severity and frequency of symptoms and their response to antireflux surgery.

METHODS

Eighty patients with GERD and Barrett's esophagus and 93 concurrent patients with GERD alone, all of whom underwent laparoscopic Nissen fundoplication, were compared by using symptom scores graded by a Likert scale.

RESULTS

Before fundoplication, patients with Barrett's esophagus had higher DeMeester scores. Symptom scores were not different for patients with versus without Barrett's esophagus before or after laparoscopic Nissen fundoplication.

CONCLUSIONS

Before and after fundoplication, patients with Barrett's esophagus, despite more severe reflux, have symptoms nearly identical in frequency and severity when compared with patients with GERD alone. Regardless of presence of Barrett's, all improve dramatically with laparoscopic Nissen fundoplication. Barrett's esophagus does not impact presentation before or outcome after laparoscopic Nissen fundoplication.

Laparoscopic treatment of Barrett's esophagus: long-term results

BACKGROUND

Gastroesophageal reflux disease (GERD) is considered the main etiologic process in the metaplastic development of Barrett's esophagus (BE). The most serious complication of BE is the possible dysplastic evolution to esophageal carcinoma. Many treatments have been described to prevent the progression of BE. The outcomes of these interventions are controversial. The aim of this study was to assess whether laparoscopic fundoplication for GERD had an impact on the development of BE.

METHODS

Prospective data were collected from patients who were treated with a laparoscopic fundoplication for BE. Data was collected and analyzed for a variety of clinical and pathologic outcomes.

RESULTS

Laparoscopic fundoplications were completed between 1993 and 2001, with a total sample size of 92 (mean age 53 +/- 11.8 years). Each patient was diagnosed with GERD associated with BE confirmed by both endoscopy and biopsy. A laparoscopic fundoplication was performed in all patients (360 degree fundoplication in 81 patients and partial fundoplication in 11 patients). There was no postoperative mortality or major complications from the procedure. The mean postoperative stay was 3 +/- 1 days. Seventy patients (76% of the overall sample size) were followed up for a mean 4.2 +/- 2.6 years. Of the patients available for follow-up, 33% (n = 23) had a complete regression of their BE; 21% (n = 15) had a decrease in the degree of metaplasia/dysplasia; 39% (n = 27) had no significant change; and 7% (n = 5) experienced a progression of the BE. Five patients required further procedures for three reasons: (1) GERD recurrence (n = 2), (2) progression of BE (n = 2), and (3) intrathoracic migration (n = 1). No patients developed high-grade dysplasia or esophageal carcinoma.

CONCLUSIONS

The results of this study suggest that laparoscopic fundoplication offers a safe and effective long-term treatment for BE. The procedure also demonstrated regression of BE in more than 50% of the sample size.

Wedge gastroplasty and reinforced crural repair: Important components of laparoscopic giant or recurrent hiatal hernia repair

OBJECTIVE

Laparoscopic repair of a giant hiatal hernia (>50% of the stomach above the diaphragm) is associated with short-term recurrence rates of 12% to 42%. Recurrent hiatal hernias often have significantly altered anatomy, making laparoscopic repair challenging. We hypothesized that increasing intra-abdominal esophageal length by means of Collis wedge gastroplasty, complete fat-pad dissection, hernia-sac excision, and primary reinforced crural repair would minimize short-term recurrence and provide adequate symptomatic relief.

METHODS

From January 1, 2001, though May 1, 2005, 61 patients underwent laparoscopic repair of a giant or recurrent hiatal hernia with a Collis wedge gastroplasty and Nissen fundoplication. Symptomatic outcomes were assessed with a validated questionnaire (Gastroesophageal Reflux Disease Health-Related Quality of Life). We obtained postoperative radiographic imaging to objectively assess anatomic results at a median of 1.13 years.

RESULTS

Of the 61 patients, 12 (20%) were referred to our institution after previous repairs. Operating time averaged 308 +/- 103 minutes. The median hospital stay was 4 days. Postoperative complications occurred in 5 (8.2%) patients. One (1.6%) patient died of cardiac complications. Postoperatively, 52 (85%) patients completed the questionnaire with mean a Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire score of 1.15 +/- 2.78 (scale, 0-45; 0 = asymptomatic). Overall, 51 (98%) of the 52 respondents were satisfied with their surgical outcome. Postoperative radiographic data were available for 54 (89%) patients. We identified no recurrences at 1-month follow-up, and only 4.7% (2/42) had evidence of radiographic recurrence at 1 year or more.

CONCLUSIONS

Consistent use of a Collis wedge gastroplasty with reinforced crural repair minimizes short-term recurrence after minimally invasive giant hiatal hernia repair. Symptomatic results are excellent in most patients.

Optimization of outcome after laparoscopic antireflux surgery

Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.

Laparoscopic fundoplication: a 10-year learning curve

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has become the most common surgical treatment for gastroesophageal reflux disease (GERD). Controversies still exist regarding the operative technique and the durability of the procedure.

METHODS

A retrospective study of 808 patients undergoing 838 LNF for GERD at a tertiary referral center was undertaken. Demographic, perioperative, and follow-up data had been entered onto the unit database.

RESULTS

During a median follow-up period of 60 months (range, 2-120 months), heartburn decreased to 3% of the patients (19/645) and regurgitation to 2% (11/582) (p < 0.01). Respiratory symptoms improved in 69 (85%) of 81 patients (p < 0.01). The incidence of postoperative dysphagia was unaffected by the use of an intraesophageal bougie (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.82-1.64; p = 0.41) or division of the short gastric vessels (OR, 0.84; 95% CI, 0.42-1.07; p = 0.72). In the immediate postoperative period, the incidence of abdominal symptoms increased by 10% (p < 0.01) and dysphagia by 16% (p < 0.01). After 10 postoperative years, only 3% (30/484) were found to have abdominal symptoms, whereas the incidence of dysphagia declined to zero.

CONCLUSION

The findings show that LNF is a safe and effective procedure with long-term durability. Abdominal symptoms and dysphagia are the principal postoperative complaints, which improve with time. Personal preference should dictate the use of a bougie, division of the short gastric vessels, or both.

Endobrachyœsophage : place de la chirurgie antireflux

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.

Antireflux surgery and esophageal mucosal DNA damage

Gastroesophageal reflux disease (GERD) is characterized by reflux of gastroduodenal contents, esophagitis and oxidative tissue damage in the distal esophagus. It may ultimately lead to the development of a pre-malignant Barrett's esophagus and subsequently to carcinoma. Antireflux surgery is an effective therapeutic tool to relieve GERD symptoms and to normalize the reflux to the distal esophagus. However, antireflux surgery may be insufficient to restore oxidative insult, which can promote DNA adduct formation and subsequent initiation of carcinogenesis. Controversy exists whether antireflux surgery can reverse the development of carcinoma in the mucosa. We aimed to test the effect of antireflux surgery on DNA adduct formation in the esophagus. Patients (n = 19) with objectively confirmed GERD underwent antireflux surgery and were followed up for 6 months after which a symptom evaluation, control endoscopy, biopsy and pH-measurements were performed. The amounts of DNA adducts in the proximal and distal mucosa of the esophagus were measured using the 32-P-postlabelling method. After the surgery, esophageal acid exposure was normalized in all the patients and symptoms were relieved in all but one patient. Endoscopic examinations showed that erosive esophagitis had healed in all the cases 6 months after the surgery. Barrett's esophagus was found in six cases in preoperative biopsies. The amount of DNA adducts in the distal esophagus was higher than in the proximal esophagus both pre- and postoperatively. Antireflux surgery did not change this pattern and was thus not capable of reducing DNA adduct formation. The level of DNA damage was similar in the patients having Barrett's esophagus compared to the rest of the patients. Antireflux surgery is insufficient to normalize DNA damage due to GERD. Our observations suggest that antireflux surgery is perhaps not effective in the prevention of carcinogenesis because of the persisting DNA damage.

Regression of intestinal metaplasia to cardiac or fundic mucosa in patients with Barrett's esophagus submitted to vagotomy, partial gastrectomy and duodenal diversion. A prospective study of 78 patients with more than 5 years of follow up

BACKGROUND

Regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's (BE) esophagus could alter the natural history of BE.

OBJECTIVE

To determine the regression of intestinal metaplasia to cardiac mucosa in patients followed more than 5 years after operation, by repeated endoscopy with biopsy.

MATERIAL AND METHODS

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 (< or =30 mm length); (2) 42 with long-segment BE (31 to 99 mm length); and (3) 5 with extra-long-segment BE (> or =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.

RESULTS

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.

CONCLUSIONS

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

Given the anatomic and functional defects almost universally present in patients who have BE, antireflux surgery is the most reliable means of stopping acid and nonacid (alkaline) reflux. Because patients who have BE have end-stage GERD, they require durable and reliable control of reflux, and the Hill procedure and partial fundoplication are associated with unacceptably high failure rates. In addition, there is mounting evidence that the success rates for Nissen fundoplication are lower in patients who have BE than in patients who have less severe GERD. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, patients who have BE must be considered at risk for having a short esophagus. The failure rate may be reduced by the liberal addition of a Collis gastroplasty, but the long-term consequences of acid-secreting mucosa left above the fundoplication in patients who have BE remain unclear. Patients suspected of having a short esophagus on the basis of a large hiatal hernia, stricture, or long-segment BE should be considered for a transthoracic approach to their fundoplication, as this affords good esophageal mobilization and may obviate the need for a gastroplasty. Surgeons must pay particular attention to their own and published results and continue to refine the operation to maximize the likelihood of a good outcome in this difficult group of patients. It is only with excellent control of reflux that any differences in the risk of progression to dysplasia and cancer become apparent, and significant, between medically and surgically treated patients.

Technical Controversies in Fundoplication Surgery

Gastroesophageal reflux disease (GERD) is a common health problem affecting more than 50% of the population. For those who experience more than occasional symptoms, GERD has a profound effect on their quality of life. With the advent of laparoscopic surgery, fundoplication has been used to treat GERD. Fundoplication also is used in the surgical management of paraesophageal hernias. Technical controversies are addressed in this article, including open versus laparoscopic approaches, the choice of complete (360 degres) or partial fundoplication, whether or not a gastroplasty is required, and the use of prosthetic materials in crural repair.

Endoscopic therapy for Barrett's esophagus

With the increase in the rate of esophageal adenocarcinoma in the United States and the Western world matched with the high morbidity and mortality of esophagectomy, there is an increasing need for new and effective techniques to treat and prevent esophageal adenocarcinoma. A wide variety of endoscopic mucosal ablative techniques have been developed for early esophageal neoplasia. However, long-term control of neoplasic risk has not been demonstrated. Most studies show that specialized intestinal metaplasia may persist underneath neo-squamous mucosa, posing a risk for subsequent neoplastic progression. In this article we review current published literature on endoscopic therapies for the management of Barrett's esophagus.

Errors in laparoscopic surgery

Laparoscopic surgery is the most significant advancement in the field of surgery over the past 15 years. This minimal access approach has been widely embraced and adopted to many common operations. Demonstrated benefits include decreased post-operative pain, shorter lengths of in-patient hospitalization, increased patient acceptance, and a more rapid return to gainful employment. With its ever-growing popularity, it has become fertile ground for civil litigation, ranking along with birth injuries and failure to diagnose cancer. A brief synopsis of the history of its evolution is presented along with general and specific comments concerning potential errors as they relate to specific common operations which are commonly done utilizing this technique.

Laparoscopic surgery for the prevention, palliation, and cure of gastrointestinal malignancies

The development of surgical laparoscopic techniques has revolutionized the way surgeons approach many diseases, including cancer. This article briefly discusses the historical development of surgical laparoscopy; describes laparoscopic surgical techniques, with a focus on techniques for common intra-abdominal malignancies; and reviews laparoscopic management of common gastrointestinal malignancies.