Can Antireflux Surgery Alter the Natural History of Barrett’s Esophagus?
Antireflux surgery (fundoplication) has become increasingly popular since the availability and development of laparoscopic approaches have made the procedure more patient friendly. It has been estimated that more than 35,000 laparoscopic Nissen fundoplications are performed annually in the United States. Fundoplication is highly effective in the short-term relief of symptoms, particularly heartburn. Few studies have carefully compared surgery to proton pump inhibitors, particularly long term, nor have critically evaluated long-term symptom relief, quality of life, and prevention of complications. The recent literature sheds light on many of these issues, including development of adenocarcinoma of the esophagus.
Lundell and colleagues recently published 5-year follow-up of a randomized study comparing open fundoplication to medical therapy with omeprazole. Three hundred and forty-four patients were initially treated with omeprazole 20 to 40 mg/day for up to 3 months. Healing of erosive esophagitis and symptom relief was achieved in 310 (76% men), who were subsequently entered into the randomized maintenance trial now with 5- and 7-year follow up.
Patients were randomized to 20 (n = 139) or 40 (n = 16) mg of omeprazole or to surgery (n = 155). The surgical procedure was chosen by the surgeon: Nissen (n = 100), (Toupet) (n = 34), or a total or posterior partial fundoplication in addition to vagotomy (in patients with concurrent duodenal ulcer) (n = 10). Endoscopy was performed at 1, 3, and 5 years after treatment and graded from 0 to 4. Symptoms were assessed: GERD-related, general dyspeptic, and postfundoplication symptoms with a rating from 0 (“no symptoms”) to 3 (“severe incapacitating symptoms”). Quality of life was assessed using both the Gastrointestinal Symptoms Rating Scale (GSRS) and Psychological General Well-Being index (PGWB). Some omeprazole failures were treated with either 40 or 60 mg daily, and outcome measures were assessed on this dosage.
The main outcome, treatment failure, was defined as one or more of the following: moderate or severe heartburn or acid regurgitation for 7 or more days before a visit; esophagitis of grade 2 or higher; moderate or severe dysphagia or odynophagia symptoms with mild heartburn or regurgitation more than 3 months after surgery; if allocated to surgery, requirement for omeprazole for more than 8 weeks to control symptoms, or reoperation; if allocated to medical therapy, needing or wanting surgery was considered treatment failure.
Analysis was by intention to treat using life-table analysis. In the surgical group, 14% had symptom relapse, 13% had esophagitis above grade 2, and 5% required more than 8 weeks of omeprazole. For reasons not stated, 11% were otherwise excluded from analysis. In the medical group, 32% had a symptom relapse, 13% had esophagitis above grade 2, and 10% had surgery during the follow-up period. Fewer patients were designated treatment failures in the surgical group than in the group treated with omeprazole 20 mg/day (P < .001). When the omeprazole dose was increased to 40 mg/day, statistical significance disappeared. Surgery is thus not a “cure” and does not completely eliminate the need for medical therapy. The study does not specifically address Barrett’s but reminds us of relative success of fundoplication compared to medical therapy. Although surgery also reduces Barrett’s length in some studies and results in regrowth and overgrowth of squamous tissue, no clear evidence suggests that pateints with Barrett’s should have surgery to prevent cancer.
Corey KE, Schmitz SM, Shaheen NJ. Does a surgical antireflux procedure decrease the incidence of esophageal adenocarcinoma in Barrett’s esophagus? A meta-analysis. Am J Gastroenterol. 2003;98(11):2390-2394.
Horwhat JD, Baroni D, Maydonovitch C, et al. Normalization of intestinal metaplasia in the esophagus and esophagogastric junction: incidence and clinical data. Am J Gastroenterol. 2007;102(3):497-506.
Lundell L, Miettinen P, Myrvold HE, et al. Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg. 2001;192:172–181.
Ye W, Chow WH, Lagergren J, et al. Risk of adenocarcinomas of the esophagus and gastric cardia in patients with gastroesophageal reflux diseases and after antireflux surgery. Gastroenterology. 2001;121(6):1286-1293.