Intestinal metaplasia in patients with columnar lined esophagus is associated with high levels of duodenogastroesophageal reflux

Barrett's esophagus: "All diseases are divine and all are human"

Barrett's esophagus (BE) is a controversial condition. The significance of this condition lies in its premalignant potential, so it is important that clinically applicable biomarkers be identified for early detection and targeted prevention. Dysplasia is currently used as main biomarker, but others most recently surveyed in cancer also include microRNAs. Classically, BE was considered to be an acquired disease related to pathological gastroesophageal acid and bile reflux. However, some cases are associated with genetic predisposition, representing an inherited, familial form of BE. The actual gene, or genes, involved in this condition have not yet been identified. Main therapeutic options include medical treatment and antireflux surgery. Both types of treatment are equally efficient in controlling symptoms and neither is able to cause the metaplastic segment to disappear, which is why the risk of malignancy remains. However, we may use endoscopic radiofrequency to eradicate BE and replace it by the typical squamous epithelium of the esophagus. The currently accepted indications of radiofrequency in BE include low- and high-grade dysplasia, but not Barrett's esophagus without dysplasia. In conclusion, BE may have two different presentations: environmental ("human", reflux) or sporadic BE, which is the most common form, and genetic ("divine", inherited) or familiar BE, less common but with a greater risk for malignancy. As they might be two different diseases, surveillance programs and treatments should also be different.

Predictive value of MicroRNAs in the progression of barrett esophagus to adenocarcinoma in a long-term follow-up study

OBJECTIVE

The aim of this study is to identify a set of microRNAs (miRNAs) as prognostic molecular biomarkers for the progression of Barrett esophagus (BE) to esophageal adenocarcinoma (EAC) to rationalize the surveillance programs in patients with BE.

BACKGROUND

Histological dysplasia is currently used as the main biomarker to identify the BE patients at high risk for developing EAC. Although miRNA expression profiles in BE and EAC have been reported, it has not been established which set of miRNAs could constitute a robust diagnostic test to predict the progression of BE to EAC.

METHODS

miRNAs associated with progression of BE to EAC were identified using miRNA sequencing analysis. Further validation by quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed in 2 groups of BE patients who either developed or did not develop adenocarcinoma after at least 5 years of follow-up.

RESULTS

Twenty-three miRNAs were identified by miRNA sequencing analysis in the carcinogenesis process associated with BE. qRT-PCR analysis using independent tissue samples confirmed differential expression for 19 of them (miR-let-7c, 7, 146a, 149, 153, 192, 192*, 194, 194*, 196a, 196b, 200a, 203, 205, 215, 424, 625, 625*, and 944). However, only miR-192, 194, 196a, and 196b showed a significantly higher expression in BE samples from patients with progression to EAC compared with those who did not progress to EAC.

CONCLUSIONS

These findings suggest that the expression pattern of a modest number of miRNAs in metaplasia biopsies could identify the BE patients at high risk for developing EAC. Therefore, it has potential use for the control and treatment of this malignancy.

Reflux esophagitis and columnar-lined esophagus after cervical esophagogastrostomy (following esophagectomy)

Reflux esophagitis (RE) and columnar-lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow-up is necessary for such patients irrespective of the route of esophageal reconstruction.

Interleukin-6, desmosome and tight junction protein expression levels in reflux esophagitis-affected mucosa

AIM: To investigate the correlation between the expression levels of interleukin (IL)-6 and proteins in tight junctions (TJs) in the esophageal mucosa of rats modeling different types of reflux esophagitis (RE), and the ability of aluminum phosphate to protect against RE-induced mucosal damage via these proteins.

METHODS: Male SPF Wistar rats aged 56 d were divided randomly into acid RE, alkaline RE, mixed RE, and control groups. Various surgical procedures were performed to establish rat models of acid RE. At 14 d after the procedure, some of the rats started aluminum phosphate treatment. Transmission electron microscopy (TEM) was used to observe the morphological features of TJs and desmosomes in the esophageal epithelium. Immunohistochemical methods and Western blotting were used to measure expression of claudin 1, occludin, ZO-1, JAM-1, DSG-1 and IL-6; reverse transcription polymerase chain reaction (RT-PCR) was used to measure expression of mRNA of claudin 1, occludin, ZO-1, JAM-1, DSG-1 and IL-6.

RESULTS: At day 14 after the procedures, an RE model was established in all subsequently sacrificed rats of groups A, B and C. By both gross and microscopic observation, the mucosa was damaged and thickened as the disease progressed. With TEM observation, a widened intercellular space was noticed, with significantly fewer desmosomes. Immunohistochemistry showed significantly higher levels of all proteins in all RE models compared to control rats at 3 d after operation (65.5% ± 25.6% vs 20.5% ± 2.1%, P < 0.05, respectively). At 14 d after operation, along with continuing hyperplasia in the basal layer, the expression of TJ proteins in individual cells gradually decreased (12.4% ± 2.1% vs 20.5% ± 2.1%, P < 0.05, respectively). Western blottings and RT-PCR showed a directly proportional increase in IL-6 levels in relation to TJ proteins, as compared to controls (0.878 ± 0.024 vs 0.205 ± 0.021 and 0.898 ± 0.022 vs 0.205 ± 0.021, P < 0.05, respectively). Upon treatment with aluminum phosphate, however, these protein levels were restored to normal gradually over 30-60 d in rats with acid RE (30.4% ± 2.1% vs 20.5% ± 2.1%, P > 0.05, treated vs untreated, respectively). These levels increased in the rat with alkaline RE, and this increase was accompanied by continued hyperplasia in comparison with controls (85.5% ± 25.6% vs 20.5% ± 2.1%, P < 0.05, respectively). Furthermore, the expression of TJ proteins was not correlated significantly with that of IL-6 in this group.

CONCLUSION: These findings indicate that TJ proteins are highly expressed as an early molecular event involved in RE development, and that IL-6 is an inflammatory factor in this process.

[Outpatient monitoring of oesophageal pH with a catheter-free pH-meter (Bravo System). A Study of tolerance, safety and efficacy]

BACKGROUND AND OBJECTIVE

A new catheter-free outpatient oesophageal pH-meter system (Bravo) has recently been developed. The objective of this study is to test the tolerance, safety and efficacy of the system in the measurement of gastric-oesophageal reflux by comparing it with a conventional pH system.

PATIENTS AND METHOD

The study was performed on a control group consisting of 10 healthy volunteers (group 1) and in a group of 40 patients with symptoms of gastric-oesophageal reflux disease (groups 2 and 3). An upper digestive system endoscopy, oesophageal manometry and oesophageal pH measurements with a conventional system and/or with the Bravo catheter-free system, was performed on all patients. All patients who had both tests done (groups 1 and 2) filled in a questionnaire on any physical problems and changes in their daily activity.

RESULTS

The test tolerance was higher with the Bravo system in the 9 parameters studied. In the group of healthy volunteers (group 1), the median (range) of the total percentage of pH < 4 was 1.1% (0.5-3.1) with the conventional pH and 1.7% (0-3.4) with the Bravo. When comparing the patients with symptoms of gastric-oesophageal reflux disease (group 2) with those who had only one type of pH measurement made, the acid reflux was significantly higher in patients with Barrett's oesophagus than in the rest of the groups, with conventional pH as well as with the Bravo. If we analyse the patient group with disease due to gastric-oesophageal reflux with those on whom both techniques were used (group 3), 7 of the 10 patients had a pathological reflux that only showed up on measuring pH with the Bravo system.

CONCLUSIONS

Catheter-free pH measurements (Bravo) is better tolerated and with better satisfaction for the healthy volunteers and patients than with conventional PH, even, on occasions being more efficient for studying acid reflux due to the lower incidence of negative results.

High risk of malignancy in familial Barrett's esophagus: presentation of one family

Barrett's esophagus is an acquired condition fundamentally related to the presence of severe and prolonged pathologic acid and biliary gastro-esophageal reflux. However, genetic factors may also play a role in some cases. The aim of this study is to present 3 generations of a Spanish family with the largest number of members so far reported with Barrett's esophagus or esophageal adenocarcinoma. Of the 24 members of this family studied over 3 generations, 6 patients developed esophageal adenocarcinoma, 4 Barrett's esophagus, 6 clinical symptoms of gastro-esophageal reflux disease without Barrett's esophagus, and 8 were asymptomatic. In conclusion, patients with familial Barrett's esophagus get the disease more severely with a high rate of malignancy and, therefore, the endoscopic surveillance should be closer than in cases of nonfamilial Barrett's esophagus.

Prevalence of Barrett's esophagus in individuals without typical symptoms of gastroesophageal reflux disease

BACKGROUND: Barrett’s esophagus, the major risk factor for esophageal adenocarcinoma, is detected in approximately 10%-14% of individuals submitted to upper endoscopy for the assessment of gastroesophageal reflux disease related symptoms. Prevalence studies of Barrett’s esophagus in individuals without typical symptoms of gastroesophageal reflux disease have reported rates ranging from 0.6% to 25%. AIM: To determine the prevalence of Barrett’s in a Brazilian population older than 50 years without typical symptoms of gastroesophageal reflux disease. METHODS: A total of 104 patients (51 men), mean age of 65 years, with an indication for upper endoscopy but without symptoms of heartburn and/or acid regurgitation (determined with a validated questionnaire) were recruited. Subjects submitted to upper endoscopic examination in the last 10 years or using antisecretory medication (proton pump inhibitors) during the last 6 months were not included. Methylene blue chromoscopy was performed during the endoscopic exam to facilitate identification of the metaplastic epithelium. RESULTS: Barrett’s esophagus was diagnosed endoscopically and confirmed by histology in four patients, all of them males. The metaplastic segment was short (less than 3 cm) and free of dysplasia in all patients. The prevalence of Barrett’s esophagus was 7.75% in the male population and 3.8% in the general population studied. CONCLUSION: Due to the low prevalence of Barrett’s esophagus found in the present study, associated with the finding of short-segment Barrett’s esophagus in all cases diagnosed and the absence of dysplasia in the material analyzed, endoscopic screening for Barrett’s esophagus in patients above the age of 50 without the classical symptoms of gastroesophageal reflux disease is not indicated for the Brazilian population.

[Surgical treatment of high-grade dysplasia in Barrett's esophagus]

INTRODUCTION

Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia.

PATIENTS AND METHOD

Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients.

RESULTS

Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14).

CONCLUSIONS

In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.

Duodenogastric reflux after esophagectomy and gastric pull-up: the effect of the route of reconstruction

Duodenogastric reflux (DGR) is a common sequel of subtotal esophagectomy and gastric pull-up, and it may contribute to mucosal changes of both the gastric conduit and the esophageal remnant. This study investigated the effect of the route of reconstruction on the DGR. 24-hour ambulatory bilirubin monitoring was performed on patients who underwent transhiatal subtotal esophagectomy and a gastric tube interposition either in the posterior mediastinum (PM group, n = 11), or in the retrosternal space (RS group, n = 8): A Control group of 8 healthy volunteers was also studied. The median percentage of reflux time, the median number of reflux episodes, and the median number of reflux episodes longer than 5 minutes, in PM versus RS groups, were 29.1% versus 0.15% (p < 0.001), 185 versus 8 (p = 0.002) and 10 versus 0 (p = 0.001), respectively. The values of the above variables in PM versus control groups were 29.1% versus 3.95% (p = 0.007), 185 versus 21 (p = 0.02), and 10 versus 2 (p = 0.009), respectively, whereas in RS versus control groups they were 0.15% versus 3.95% (p = 0.01), 8 versus 21 (p = 0.04), and 0 versus 2 (p = 0.05), respectively. Posterior mediastinal gastric interposition is associated with high reflux of duodenal contents, whereas retrosternal interposition minimizes the reflux at levels even lower than those of the healthy individuals. The latter type of reconstruction may be a good alternative from that perspective, especially in patients with long life expectancy.

Evaluation of esophageal function for antireflux surgery

Antireflux surgery has become well established as an effective and durable therapy for gastroesophageal reflux disease and its complications. The outcome of antireflux surgery, however, is only as good as the evaluation to document the association between pathologic esophageal acid exposure and the patient's symptoms. This article discusses the well-established diagnostic modalities used to assess foregut structure and function and includes several more sophisticated secondary studies that may aid the clinician in elucidating the cause of the problem in patients in whom standard testing is inadequate.

Barrett's oesophagus: the new endoscopic modalities have a future

Barrett's oesophagus is defined as the replacement of squamous oesophageal epithelium by intestinal metaplasia in the distal oesophagus. It is a fairly frequent complication of gastro-oesophageal reflux disease (GORD): 5-10% of patients with GORD suffer from Barrett's oesophagus. GORD is essential for the development of Barrett's oesophagus.1 Intestinal metaplasia is a premalignant lesion that may further develop into dysplasia and lead to adenocarcinoma of the oesophagus. The latter now accounts for almost 50% of oesophageal cancer cases in western countries, and the largest increase in its incidence was recorded during the past two decades. Patients with Barrett's oesophagus have a 2-25% risk of developing mild to severe dysplasia and a 2-5% risk of having adenocarcinoma: 30-150 times higher than the risk in the general population. Forty to fifty per cent of Barrett's oesophagus patients with severe dysplasia would present adenocarcinoma within 5 years.

Barrett's esophagus in females: a comparative analysis of risk factors in females and males

OBJECTIVES

Gastroesophageal reflux symptoms occur with similar frequency in males and females, yet Barrett's esophagus is less common in females. The reason for this disparity is unknown. The aim of this study was to determine the factors related to Barrett's in females.

METHODS

The records of 796 patients (462 male, 334 female) evaluated from 1990 to 2000 for symptoms of reflux were retrospectively reviewed. Physiologic abnormalities based on results of endoscopic, motility, pH, and Bilitec testing were identified, and factors related to the presence of Barrett's were determined using univariate and multivariate analysis.

RESULTS

Females with reflux symptoms were significantly less likely to have a positive 24-h pH test, a defective lower esophageal sphincter, or a hiatal hernia than males with reflux symptoms. Further, females with reflux on the basis of an abnormal 24-h pH test had significantly less esophageal acid exposure than males with reflux. In contrast, esophageal exposure to refluxed acid and bilirubin was similar in females (n = 50) and males (n = 136) with Barrett's. On multivariable analysis increased esophageal bilirubin exposure was the only significant factor associated with the presence of Barrett's in male and female patients with reflux disease.

CONCLUSIONS

Females with reflux symptoms have less esophageal acid exposure on average than males. However, females and males with Barrett's have a similar severity of reflux, and the female gender does not protect against the development of Barrett's in the setting of advanced reflux disease. Esophageal bilirubin exposure is the major risk factor for the presence of Barrett's in patients with reflux disease.

Ambulatory combined pH, bile and manometric monitoring of the oesophagus in asymptomatic healthy volunteers

BACKGROUND

With the development of sophisticated equipment ambulatory studies of oesophageal motor function, pH and bilirubin have gained in popularity. The aim of the study was to present reference values for combined 24 h pH, bilirubin and manometric measurements of the oesophagus.

METHODS

Twenty-six (15 male) healthy volunteers without symptoms of gastro-oesophageal reflux underwent a 24-h ambulatory oesophageal combined three-channel pressure, acid and bilirubin detection.

RESULTS

The subjects were studied for a median of 20 h (16-22). The median per cent time with pH < 4 for the whole measured time was 3.1 (0.8-14; 5 and 95 percentiles). Bile was detected for a median of 0.05% (0.0-8.5; 5 and 95 percentiles) of the time. Eighty-one per cent of the contractions were peristaltic, 55% of which were complete. Of these, 53% had a pressure over 30 mmHg at all three pressure points, giving an efficient peristalsis in a median of 29% (13-46; 5 and 95 percentiles) of all registered contractile patterns. No difference between the genders could be observed.

CONCLUSIONS

This study provides normative data for ambulatory oesophageal manometry, pH and bilirubin studies that can be used for comparing with patients with disease.

Esophagogastrectomy without pyloroplasty

There is no consensus on the need for pyloroplasty after esophagectomy or proximal gastrectomy with an esophagogastrostomy and vagotomy. Arguments for routine pyloroplasty include prevention of postoperative delayed gastric emptying. Arguments against include prevention of postoperative dumping syndrome and bile reflux esophagitis. The purpose of this study was to assess clinical outcomes of patients undergoing esophagogastrectomy without routine pyloroplasty. All patients undergoing esophagogastrectomy or proximal gastrectomy with esophagogastrostomy from October 1996 to September 2002, inclusive were reviewed for age, gender, diagnosis, type of resection, pathology, short-term complications, long-term complications, remedial procedures performed, and postoperative gastric emptying scintigraphy. 58 patients were studied. Postoperative mortality was 6.9%, and anastomotic leak rate 12.1%. Eleven patients (19%) had symptomatic gastroparesis, two required pyloric balloon dilation and one a pyloroplasty. No patients complained of dumping symptoms; reflux requiring medical intervention occurred in seven (12.1%), and anastomotic stricture requiring dilation occurred in five (8.6%). Omitting a pyloroplasty does not lead to a high frequency of symptomatic delayed gastric emptying. Maintaining the pylorus may protect patients from dumping syndrome, and bile reflux esophagitis with its potential noxious effects on the remaining esophageal mucosa.

Argon plasma coagulation in Barrett's esophagus

Despite the availability of many clinical trials, there is no evidence that APC has any role in the management of Barrett's esophagus. Ablation therapy is not indicated for nondysplastic Barrett's esophagus (and this is true, whatever the technique used), and it should not be performed outside of a carefully designed and approved clinical trial. Indeed, these patients have a low risk of cancer, and there is no evidence that Barrett's esophagus ablation will be of any benefit for these patients. In some cases, APC could be of some help, especially for treating short segments of dysplastic Barrett's esophagus. In this field, however, it competes with the growing indication of mucosectomy, which clearly offers advantages in terms of treatment's quality control assessment.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus

OBJECTIVE

To compare the results of medical treatment and antireflux surgery in patients with Barrett's esophagus (BE).

SUMMARY BACKGROUND DATA

The treatment of choice in BE is still controversial. Some clinical studies suggest that surgery could be more effective than medical treatment in preventing BE from progressing to dysplasia and adenocarcinoma. However, data from prospective comparative studies are necessary to answer this question.

METHODS

One hundred one patients were included in a randomized prospective study, 43 with medical treatment and 58 with antireflux surgery. All patients underwent clinical, endoscopic, and histologic assessment. Functional studies were performed in all the operated patients and in a subgroup of patients receiving medical treatment. The median follow-up was 5 years (range 1-18) in the medical treatment group and 6 years (range 1-18) in the surgical treatment group.

RESULTS

Satisfactory clinical results (excellent to good) were achieved in 39 of the 43 patients (91%) undergoing medical treatment and in 53 of the 58 patients (91%) following antireflux surgery. The persistence of added inflammatory lesions was significantly higher in the medical treatment group. The metaplastic segment did not disappear in any case. Postoperative functional studies showed a significant decrease in the median percentage of total time with pH below 4, although 9 of the 58 patients (15%) showed pathologic rates of acid reflux. High-grade dysplasia appeared in 2 of the 43 patients (5%) in the medical treatment group and in 2 of the 58 patients (3%) in the surgical treatment group. In the latter, both patients presented with clinical and pH-metric recurrence. There was no case of malignancy after successful antireflux surgery.

CONCLUSIONS

These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) affects many patients and has a negative effect on quality of life. Along with the increasing prevalence of GERD is an increase in GERD-related complications, including Barrett esophagus and esophageal adenocarcinoma. The past year has yielded new insights into the pathophysiology of GERD that can help us to better understand the relationship between reflux episodes and symptoms of mucosal damage and to provide a tailored treatment targeting individual pathophysiologic defects. The issues addressed in this report include gastric secretory and motor dysfunction; failure of the antireflux barrier caused by hiatal hernia and transient lower esophageal sphincter relaxations; characterization of the refluxate, particularly of nonacid reflux; prevalence and prognostic value of esophageal dysmotility in GERD; presence and eradication of Helicobacter pylori; Barrett esophagus and extraesophageal manifestations of GERD; and, finally, advances in medical, endoscopic, and surgical treatments of GERD.

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.