Antireflux surgery, highly selective vagotomy and duodenal switch procedure: post-operative evaluation in patients with complicated and non-complicated Barrett's esophagus

ENDOSCOPIC ABLATION COMBINED WITH FUNDOPLICATION PLUS ACID SUPPRESSION-DUODENAL DIVERSION PROCEDURE FOR LONG SEGMENT BARRETT´S ESOPHAGUS: EARLY AND LONG-TERM OUTCOME

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.

Late esophagogastric anatomic and functional changes after sleeve gastrectomy and its clinical consequences with regards to gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is described as a complication after sleeve gastrectomy. Most studies have used only clinical symptoms or upper gastrointestinal endoscopy for evaluation of reflux after surgery. Manometry, acid reflux tests, and esophageal barium swallow have not been commonly used. The objective of this study is to evaluate the short- and long-term incidence of clinical gastroesophageal reflux, the lower esophageal sphincter (LES) pressure, acid reflux, and endoscopic and radiological changes after sleeve gastrectomy (SG). A total of 315 patients were studied after SG; 248 (78.3%) completed more than 5 years of follow-up and 67 (21.4%) have more than 8 years (range 8-10 years) of follow-up. The preoperative weight was 106 + 14.1 kg with a mean body mass index 38.4 + 3.4 kg/m2. Patients with prior GERD were excluded for SG. During the follow-up patients were subjected to clinical, endoscopic, radiological, manometric, and 24-hour pH monitoring and duodenogastric reflux evaluations. Reflux symptoms were observed in 65.1% of patients at late follow-up. Patients without reflux symptoms presented an LES resting pressure of 13.3 ± 4.2 mmHg while patients with reflux symptoms presented an LES resting pressure of 9.8 + 2.1 mmHg. In patients with reflux symptoms, a positive acid reflux test was observed in 77.5% of patients with a mean DeMeester score of 41.7 ± 2.9 (range 14.1-131.7). During endoscopy, esophagitis was found in 29.4%, hiatal hernia in 5.7%, and Barrett's esophagus was diagnosed in 4.8%. Positive duodenogastric reflux was found in 31.8% of patients and 57.7% of our patients received proton pump inhibitor treatment after SG. Sleeve gastrectomy presents anatomic and functional changes that are associated with increased GERD.

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Surgical therapy of gastro-oesophageal reflux disease

Surgery should always be looked upon as complementary to medical therapy in the long-term management of patients with chronic GORD. Available medical therapies are effective and adequate for the control of disease manifestations in the great majority of GORD patients. For patients who have a suboptimal disease control under medical therapy and in those who for various reasons want to discuss an alternative to medical long-term therapy, the following message can be transmitted. Anti reflux surgery is a well-documented effective long-term therapeutic alternative to control GORD. The outcome after surgery is dependent on the experience and quality of the surgeon. These operations are safe but mortality can never attain a zero level and the morbidity has to be realised. Anti reflux surgery has to be centralised within each country. With the aim of optimising the outcome of anti reflux surgery, the surgeon has to perform and master a delicate act of balance on the choice between various fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated somewhat more frequent mechanical side-effects. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without compromising the level of reflux control and can therefore often be recommended. Most studies present very promising results following anterior partial fundoplications. The spectrum of postfundoplication symptoms can be minimised provided that the surgeon fully comprehend the mechanism of action of these procedures and adhere to technical perfectionism. Evaluation and management of failures after anti reflux surgery have to be centralised within each country.

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.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

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.

Nonesophageal side-effects after antireflux surgery plus acid-suppression duodenal diversion surgery in patients with long-segment Barrett's esophagus*

During the last years we have employed acid-suppression duodenal diversion procedures (truncal vagotomy-partial gastrectomy plus Roux-en-Y gastrojejunostomy) in addition to antireflux surgery in order to treat all the pathophysiological factors involved in the genesis of Barrett's esophagus. We have observed very good results concerning the clinical and objective control of GERD at the long-term follow up after this procedure. However, it could be associated with other nonesophageal symptoms or side-effects. This study was conducted to evaluate the presence of gastrointestinal symptoms (diarrhea, vomiting, dumping, weight loss and anastomotic ulcers) after this operation. In this prospective study 73 patients were assessed using a careful clinical questionnaire asking regarding these complications at the early (< 6 months) and late (> 6 months) follow-up (average of 32.4 months). In the early postoperative period, diarrhea was present in 64% (19% considered severe 10-90 days after surgery), dumping in 41% and loss of weight in 71% of cases. Diarrhea occurred daily in 47.7% in the early postoperative period, but only in 16% of cases after 1 year. Shortly after surgery, steatorrea was observed in 9% of cases and responded well to medical treatment. Severe diarrhea or dumping was rare (5% of cases). These symptoms improved significantly after 1 year with medical management (45%, 20% and 30%, respectively) and 42% of patients regained their normal body weight. Only two patients presented anastomotic ulcers and were treated satisfactory with proton pump inhibitors. Revisional surgery was indicated in two patients with severe dumping syndrome. Most side-effects identified by this study were mild and diminished 1 year after operation.

Histological inflammatory changes after surgery at the epithelium of the distal esophagus in patients with Barrett's esophagus: a comparison of two surgical procedures

There are many reports concerning the surgical treatment of patients with Barrett's esophagus, but very few focus on histological changes of inflammatory cells in squamous and columnar epithelium before and late after classic antireflux or acid suppression-duodenal diversion surgery. We evaluate the impact of these procedures in the presence of intestinal metaplasia, dysplasia and Helicobacter pylori in the columnar epithelium. Two groups of patients were studied, 37 subjected to classic antireflux and 96 to acid suppression-duodenal diversion operations. They were subjected to endoscopic and histological studies before and at 1, 3 and more than 5 years after surgery. Manometric evaluations and 24 h pH monitoring were performed before and at 1 year after surgery. The presence of inflammatory cells at both the squamous and columnar epithelium was significantly higher at the late follow up in patients subjected to classic antireflux surgery compared with patients subjected to acid suppression-duodenal diversion operations (P < 0.02 and P < 0.001, respectively). Intestinal metaplasia, present in 100% of patients before surgery, had decreased significantly at 3 years after surgery in patients subjected to acid suppression-duodenal diversion operations compared with classic antireflux procedures, 75% versus 53%, respectively (P < 0.001). The presence of Helicobacter pylori did not vary before or after surgery in either group. In conclusion, acid suppression-duodenal diversion operations are followed by a decreased presence of inflammatory cells in both squamous and columnar epithelium compared with classic antireflux surgery in patients with Barrett's esophagus. Intestinal metaplasia and dysplasia and inflammation findings were also less common after acid suppression-duodenal diversion operation.

Results of surgical treatment for recurrent postoperative gastroesophageal reflux

The rate of recurrence of reflux esophagitis after classic antireflux surgery (fundoplication) is 10-15%. This rate is different in patients with esophagitis with and without Barrett's esophagus. We evaluated the clinical and laboratory findings in 104 patients with postoperative recurrent reflux esophagitis, determining the results of repeat antireflux surgery or an acid suppression-bile diversion procedure. Repeat fundoplication was performed in 26 patients, and truncal vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in 78 patients. Esophagectomy as a third operation was performed in seven patients. After repeat antireflux surgery, endoscopic evaluation demonstrated improvement of esophagitis in a small proportion of patients. Barrett's esophagus remained unchanged, and no regression of ulcer or stricture was observed. These complications improved significantly after acid suppression-bile diversion surgery. Incompetent lower esophageal sphincter (LES) was present in 55.8% after initial surgery and in 23% after reoperation. Acid reflux, initially present in 94.6% of patients, was also observed in 93.6% after fundoplication, 68.8% after redo fundoplication, and 16.6% after treatment with the acid suppression-bile diversion technique. A positive Bilitec test was present in 78% of patients before the operation and 56.6% after the repeat operation, and was negative after bile diversion surgery. Among 13 patients (50%) submitted to repeat surgery alone, esophagectomy as a third operation was necessary as a result of severe non-dilatable stricture in seven patients. Our conclusions are that repeat antireflux surgery alone failed to improve Barrett's esophagus complications and that the best results were obtained in patients submitted to acid suppression-bile diversion surgery.

Barrett's esophagus without esophageal stricture does not increase the rate of failure of Nissen fundoplication

OBJECTIVE

To assess whether the presence of Barrett's esophagus (BE) modifies the results of Nissen fundoplication.

SUMMARY BACKGROUND DATA

Some authors consider that BE, whether or not there is associated stricture, significantly increases the failure rate of standard antireflux surgery; they recommend using different and more aggressive surgical procedures in all patients with BE.

METHODS

One hundred seventy-seven patients with gastroesophageal reflux disease, without esophageal stricture, were included in a retrospective study. Patients were divided into two groups: those with BE (n = 57) and those without BE (n = 120). Nissen fundoplication was performed in all patients by the same surgical team. Clinical, endoscopic, and functional (manometry and 24-hour pH monitoring) results in the two study groups were compared.

RESULTS

After a median follow-up of 5 years (range 1-18) in the BE group and 6 years (range 1-18) in the non-BE group, the rate of clinical recurrence was 8% in the BE group and 10% in the non-BE group, with no statistically significant difference. The rate of pH-metric recurrence was the same in both groups (15%).

CONCLUSIONS

The presence of BE without esophageal stricture does not increase the rate of failure of Nissen fundoplication.

Standard antireflux operations in patients who have Barrett's esophagus. Current results

Several therapeutic options exist for patients who have BE, and treatment should be individualized (Fig. 1). The best option in patients who have a high surgical risk or who reject surgery is lifelong conservative treatment, adjusting the PPI dosage with pH-metric controls. In patients who have a low surgical risk the best option is Nissen fundoplication. Only in cases in which esophageal shortening prevents a tension-free fundoplication from being done is a Collis gastroplasty associated with a fundoplication indicated. Other options may be indicated only in exceptional circumstances: (a) duodenal switch, when, after multiple failures with previous surgery, the approach to the esophagogastric junction is extremely difficult; and (b) esophageal resection, when there is a nondilatable esophageal stenosis and in cases in which the histologic study reveals the presence of high-grade dysplasia. Whatever treatment is used, an endoscopic surveillance program is mandatory, since, with the exception of total esophagectomy, no therapeutic option completely eliminates the risk for progression to adenocarcinoma.