Development of Barrett's esophagus six months after total gastrectomy

Development of Barrett's esophagus after a total gastrectomy

Bile reflux is a complication that could develop in patients with total gastrectomy. The role of biliary reflux in Barrett's esophagus after a total gastrectomy continues to be controversial. Therefore, we report a series of three cases that describe the development of BE after total gastrectomy and provides additional support on the role that bile reflux plays in patients with BE.

Jejunal pouch reconstruction after total gastrectomy is associated with better short-term absorption capacity and quality of life in early-stage gastric cancer patients

Background

No consensus exists regarding the best reconstruction style after total gastrectomy (TG). Roux-en-Y oesophagojejunostomy is a simple option for gastrointestinal tract reconstruction. Recently, jejunal pouch reconstruction has been suggested as an appropriate approach. We compared the postoperative outcomes of the two surgical approaches using a well-characterized cohort of gastric carcinoma patients.

Methods

A total of 60 patients who underwent TG were divided into two groups according to the reconstruction style. Both groups were compared regarding patient characteristics, perioperative data and quality of life (QoL), which was assessed using the Spitzer QoL index (QLI) and Visick grade. The incidence of long-term surgery-related complications, including reflux oesophagitis, dumping syndrome, and retention syndrome, was also compared to evaluate postoperative restoration.

Results

Both study groups were comparable with respect to general patient characteristics. No mortality or no significant differences in surgery-related data were found except in the operation time. Compared to Orr Roux-en-Y reconstruction, pouch reconstruction was associated with a longer procedure time, a lower incidence of dumping/retention syndrome and better QoL parameters (p < 0.05).

Conclusion

In this study, jejunal pouch reconstruction after TG was superior to the traditional Roux-n-Y oesophagojejunostomy with respect to improved dietary intake and QoL.

Clinical outcomes of endoscopic submucosal dissection for superficial Barrett's adenocarcinoma

BACKGROUND

Advances in diagnostic techniques have allowed early stage detection of superficial Barrett's adenocarcinoma (SBA) as well as resection by endoscopic submucosal dissection (ESD). Few reports exist, however, on the safety and efficacy of ESD for SBA.

OBJECTIVE

To analyze outcomes of ESD for SBA in relation to clinicopathological features of the lesions.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

Twenty-three patients (21 men, 2 women; mean age, 63 years) with 26 SBAs.

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

We examined outcomes of ESD in relation to the clinicopathological features of SBAs. The main outcomes assessed were en bloc resection rate, operation time, adverse event rates, additional resection rate, and time between ESD and any recurrence.

RESULTS

Twenty lesions (87%) derived from short-segment Barrett's esophagus, and 3 lesions (13%) derived from long-segment Barrett's esophagus. The majority of SBAs (54%) were located in the 0 to 3 o'clock circumferential quadrant. Median tumor size was 15 mm (range 5-60 mm). Macroscopic types were flat elevated (n = 13, 50%), depressed (n = 12, 46%), and protruded (n = 1, 4%). The SBAs appeared red (n = 23, 88%) or normally pale (n = 3, 12%). Under magnifying narrow-band imaging, all SBAs showed an irregular mucosal pattern and an irregular vascular pattern. The endoscopic en bloc resection rate was 100% (26/26), and the pathological en bloc resection rate was 85% (22/26). The median procedure time was 95 minutes (range, 30-210 minutes). Delayed bleeding occurred in 1 case, but there was no perforation. The SBAs were of the differentiated type (n = 25, 96%) or poorly differentiated type (n = 1, 4%). The tumor had invaded the superficial muscularis mucosa (n = 3, 12%), lamina propria mucosa (n = 5, 19%, deep muscularis mucosa (n = 9, 34%), SM1 (n = 3, 12%), and SM2 (n = 6, 23%). Additional surgical resection after ESD was performed in 9 cases, and there were no residual tumors, but 1 lymph node metastasis was found. There were no recurrent tumors; however, 1 metachronous adenocarcinoma was diagnosed 42 months after ESD.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

ESD appears to be a safe and effective treatment strategy for early stage SBA.

Adenocarcinoma in long-segment Barrett's esophagus 44 years after total gastrectomy

Although Barrett's esophagus may occur without gastric acid, Barrett's adenocarcinoma after total gastrectomy is rare. Here, we present Barrett's adenocarcinoma in long-segment Barrett's esophagus after total gastrectomy. The patient was a 74-year-old male who underwent total gastrectomy 44 years ago. An endoscopic examination revealed long-segment Barrett's esophagus starting 17 cm from the incisors and continuing 20 cm to esophagojejunostomy, with irregular mucosa 27-31 cm from the incisors. Pathological diagnosis of a biopsied specimen was adenocarcinoma. We performed subtotal esophagectomy with lymph node dissection in the prone position and reconstructed the esophagus with ileocolic interposition. Postoperative pathological diagnosis from a Barrett's epithelial section was well differentiated adenocarcinoma. This case had the longest interval from total gastrectomy and smallest oral margin of Barrett's epithelium. Our case suggested that careful surveillance is needed for patients exhibiting recurrent bile reflux following total gastrectomy.

Differences in the Characteristics of Barrett's Esophagus and Barrett's Adenocarcinoma between the United States and Japan

In Europe and the United States, the incidence of esophageal adenocarcinoma has increased 6-fold in the last 25 years and currently accounts for more than 50% of all esophageal cancers. Barrett's esophagus is the source of Barrett's adenocarcinoma and is characterized by the replacement of squamous epithelium with columnar epithelium in the lower esophagus due to chronic gastroesophageal reflux disease (GERD). Even though the prevalence of GERD has recently been increasing in Japan as well as in Europe and the United States, the clinical situation of Barrett's esophagus and Barrett's adenocarcinoma differs from that in Western countries. In this paper, we focus on specific differences in the background factors and pathophysiology of these lesions.

The effect of long-term control of reflux by fundoplication on aberrant deoxyribonucleic acid methylation in patients with Barrett esophagus

OBJECTIVE

We investigated the relationship between reflux and aberrant deoxyribonucleic acid (DNA) methylation, comparing methylation in the columnar epithelium following successful fundoplication to that in subjects with a failed fundoplication.

SUMMARY BACKGROUND DATA

Gastroesophageal reflux is the main risk factor for Barrett esophagus and adenocarcinoma. In these diseases, there is a high level of DNA methylation.

METHODS

We enrolled 41 patients with Barrett esophagus and a fundoplication at least 5 years earlier for a 24-hour pH study, endoscopy, and collection of biopsies. Biopsies were obtained from 17 Barrett esophagus subjects who had not undergone esophageal surgery.

RESULTS

At the time of the study, 31 subjects were pH normal, 10 abnormal. Columnar biopsies were collected from 21 of the pH normal and 9 pH abnormal subjects, and all no surgery subjects. Complete regression of columnar mucosa was seen in 7 subjects with pH normal and 1 with pH abnormal. The length of Barrett esophagus did not differ between groups preoperatively, but was significantly less at the time of the study in the pH normal compared with pH abnormal or no surgery groups. Significantly, fewer genes were methylated in the pH normal than the pH abnormal or no surgery groups, which did not differ from each other. The number of methylated genes correlated with increased reflux, intestinal metaplasia, and increased columnar-lined esophagus length, but not acid-suppression medication.

CONCLUSIONS

Fundoplication that reduces reflux to normal levels can lead to regression of the columnar mucosa. Reflux is associated with aberrant DNA methylation, and control of reflux reduces deleterious genomic changes associated with cancer.

Comparison of gastroesophageal reflux in 100 patients with or without prior gastroesophageal surgery

BACKGROUND AND PURPOSE

The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD.

METHODS

One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed.

RESULTS

Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett's esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients.

CONCLUSION

The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.

Development of Barrett's Esophagus Soon after Total Gastrectomy

The role of duodenal reflux and the time required for the development of Barrett's esophagus has remained controversial. We report a case of Barrett's esophagus that developed 6 months after total gastrectomy. A 76-year-old man diagnosed with gastric adenocarcinoma underwent a total gastrectomy and a Rouxen-Y esophagojejunostomy. The gastroesophageal junction in the resected specimen was both grossly and microscopically normal at the time of the operation. A routine follow-up endoscopic examination performed 6 months later revealed a tongue-like projection of redcolored columnar tissue. No reflux symptoms (heartburn or acid regurgitation) had been present during the intervening 6 months. A biopsy specimen from the esophagus showed intestinal-type metaplasia of the columnar epithelium. This case supports the development of Barrett's esophagus solely from duodenal reflux and after a relatively short time in this clinical setting.

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.

Small-bowel metaplasia arising in the remnant esophagus after esophagojejunostomy--a [corrected] prospective study in patients with a history of total gastrectomy

OBJECTIVES

The pathogenesis of Barrett's mucosa is incompletely understood. Acidic gastro-esophageal reflux is considered an essential causative factor. The aim of this study was to detect esophageal columnar metaplasia after total gastrectomy with esophagojejunostomy, a condition of enteric, but nonacidic reflux.

METHODS

In a prospective study, patients with a history of total gastrectomy and esophagojejunostomy were investigated for the presence of columnar metaplasia in the remnant esophagus. Patients with such history, who were now referred for esophagogastroduodenoscopy, were included during a 2-yr period. Biopsies for histopathology were taken from the anastomosis and any columnar metaplasia of the esophagus.

RESULTS

In 8 of 25 patients (32%) with a history of gastrectomy, columnar metaplasia was found in the remnant esophagus, mostly in shape of tongues, partly associated with erosive reflux esophagitis. Histopathology showed a typical small-bowel mucosa, but with some villous atrophy. In a resection specimen, a double-layered muscularis mucosa was present, which proved the metaplastic nature of the intestinal mucosa. Length of the columnar metaplasia correlated with the time interval since surgery.

CONCLUSIONS

Esophageal mucosa, if exposed long term to an enteric, but nongastric refluxate, can evolve into a highly differentiated intestinal metaplasia, which resembles small-bowel mucosa. This proves that complete-type intestinal metaplasia may arise not only in the stomach, but also in the esophagus. Esophageal intestinalization seems to reflect adaptation to enteric reflux.