Extended and limited types of Barrett's esophagus in the adult

Shape of Barrett’s epithelium is associated with prevalence of erosive esophagitis

AIM: To test the hypothesis that the shape and length of Barrett’s epithelium are associated with prevalence of erosive esophagitis.

METHODS: A total study population comprised 869 patients who underwent endoscopy during a health checkup at our hospital. The presence and extent of Barrett’s epithelium were diagnosed based on the Prague C & M Criteria. We originally classified cases of Barrett’s epithelium into two types based on its shape, namely, flame-like and lotus-like Barrett’s epithelium, and into two groups based on its length, its C extent < 2 cm, and ≥ 2 cm. Correlation of shape and length of Barrett’s epithelium with erosive esophagitis was examined.

RESULTS: Barrett’s epithelium was diagnosed in 374 cases (43%). Most of these were diagnosed as short-segment Barrett’s epithelium. The prevalence of erosive esophagitis was significantly higher in subjects with flame-like than lotus-like Barrett’s epithelium, and in those with a C extent of ≥ 2 cm than < 2 cm.

CONCLUSION: Flame-like rather than lotus-like Barrett’s epithelium, and Barrett’s epithelium with a longer segment were more strongly associated with erosive esophagitis.

Risk factors for the progression of endoscopic Barrett's epithelium in Japan: a multivariate analysis based on the Prague C & M Criteria

PURPOSE

To determine the prevalence and progression of Barrett's epithelium and associated risk factors in Japan.

METHODS

The study population comprised 869 cases. Endoscopic Barrett's epithelium was diagnosed based on the Prague C & M Criteria. The correlations of clinical factors with the prevalence and progression of endoscopic Barrett's epithelium were examined.

RESULTS

Endoscopic Barrett's epithelium was diagnosed in 374 cases (43%), in the majority of which the diagnosis was short-segment Barrett's esophagus. The progression of Barrett's epithelium was identified in 47 cases. In univariate and multiple logistic regression analyses, aging, smoking habit, and erosive esophagitis were significantly associated with the prevalence of Barrett's epithelium, whereas aging and erosive esophagitis, especially severe erosive esophagitis, were significant contributing factors to the progression of Barrett's epithelium.

CONCLUSIONS

Forty-three percent of the total study population was diagnosed as having endoscopic Barrett's epithelium. During the follow-up period, 12.6% of the cases with Barrett's epithelium exhibited progression which was associated with aging and severe erosive esophagitis.

Columnar-lined esophagus: time to drop the eponym of "Barrett": Historical review

There can be few medical conditions that have been surrounded by as much confusion about their definition or terminology as columnar-lined esophagus (CLE); approximately 30 different terms and eponyms have been used to describe this condition. The history of this condition can be divided into five stages: (i) descriptive stage, 1906-1950; (ii) "argument" stage, 1950-1963; (iii) "significant" stage, 1963-1973; (iv) surveillance stage, 1973-1990; and (v) refined research stage, 1990-present. The use of the eponym "Barrett's" to describe CLE is not justified from a historical point of view. Lining of the lower esophagus by columnar epithelium was termed "Barrett's esophagus" after the presentation by Barrett in 1957. Although this finding has been attributed to Barrett, the work of others, including Tileston, Lortat-Jacob, and Allison and Johnstone, preceded Barrett's description. The historical aspects of CLE were reviewed to show how little Norman Barrett had contributed to the core concept of this condition in comparison to the contributions of other investigators, particularly the contribution of Philip Allison. Based on many discussed historical facts, we are not in favor of retaining the term "Barrett's esophagus" and we propose that CLE be henceforth referred to as "columnar-lined esophagus".

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.

Pathogenesis of columnar-lined esophagus

Since its initial description, the pathogenesis of the columnar-lined esophagus (CLE) has been surrounded by many controversies. The first controversy is related to the existence of the condition itself. The second controversy centers on whether the CLE is a congenital or an acquired condition. In this article, we review the congenital and acquired theories of development of CLE and discuss the various factors in acquisition of CLE. The bulk of evidence in the literature suggests that CLE is an acquired condition.

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.

Antireflux surgery for Barrett's esophagus: comparative results of the Nissen and Collis-Nissen operations

Using a Collis-Nissen repair instead of a standard Nissen fundoplication to treat the reflux disease of Barrett's esophagus is controversial. This paper compares the Nissen and Collis-Nissen operations when treating Barrett's esophagus. Thirty-three patients with documented Barrett's esophagus (male : female, 26 : 7, median age, 48.8 years) had a Nissen fundoplication during 1976-1989. Fifty-one patients (male : female = 41 : 10, median age = 53.2 years) underwent a Collis-Nissen operation between 1990 and 1999. Clinical assessments, esophagogram, radionuclide emptying, manometry, 24-h pH study, and endoscopy were obtained pre- and postoperatively. There was no operative death in either group. Median follow-up was 8.0 years for the Nissen group and 6.5 years for the Collis group. Postoperative reflux symptoms were more frequent in the Nissen group (52%) when compared to the Collis group (7%, P < 0.001). These symptoms correlated with the 24-h pH recordings revealing an increased acid exposure in the Nissen group (3.4%) as opposed to 1% in the Collis group (P = 0.003). Endoscopy revealed mucosal erosions and ulcers in 39% of patients receiving a standard Nissen repair while these damages were seen in 7% of patients who were offered an elongation gastroplasty with a total fundoplication (P = 0.007). The cumulative success rate was 83% for the Nissen group and 100% for the Collis group at 5 years, and 63% versus 90% at 10 years (Log-rank test, P = 0.004). The Collis-Nissen fundoplication provides better reflux protection for Barrett's patients than a standard Nissen repair. It lowers the risk of fundoplication failure.

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.

Surgical treatment of Barrett's esophagus: 1980-2003

Barrett's esophagus is a complication of long-standing gastroesophageal reflux and can be a premalignant condition. The goals of surgical treatment, which were well summarized by DeMeester, have been increased and more detailed by us. They consist of (1) controlling symptoms of gastroesophageal reflux disease; (2) abolishing acid and duodenal reflux into the esophagus; (3) preventing or eliminating the development of complications; (4) preventing extension of or an increase in the length of intestinal metaplasia; (5) inducing regression of intestinal metaplasia to the cardiac mucosa; and (6) preventing progression to dysplasia, thereby inducing regression of low-grade dysplasia and avoiding the appearance of an adenocarcinoma. We have reviewed 25 articles in the English-language literature published from 1980 to 2003 dealing specifically with the surgical treatment of Barrett's esophagus. In most of these papers too few patients were included, the follow-up was less than 60 months, and the clinical success deteriorated with time. Acid reflux persists after surgery in nearly 35% of Barrett's esophagus patients; and at 10 years after surgery duodenal reflux is present in 95%. Peptic ulcer, stricture, and erosive esophagitis are present in 15% to 30% late after surgery, and in 16% there is progression of the intestinal metaplasia. There is the appearance of low-grade dysplasia in 6.0% and adenocarcinoma in 3.4%, and there is regression of low-grade dysplasia in 45.0%. These results challenge the arguments supporting antireflux surgery for patients with Barrett's esophagus: The clinical results are not optimal, no long-lasting effect has been demonstrated, and it does not prevent the appearance of dysplasia or adenocarcinoma. An excellent alternative is acid suppression and a duodenal diversion procedure, which has had 91% clinical success for more than 5 years. This regimen has almost eliminated acid and duodenal reflux, and there has been no progression to dysplasia or adenocarcinoma. Moreover, in 60% of the patients with low-grade dysplasia, regression to nondysplastic mucosa has occurred.

Screening for Barrett's esophagus in colonoscopy patients with and without heartburn

BACKGROUND & AIMS

The population prevalence of Barrett's esophagus (BE) is uncertain. Our aim was to describe the prevalence of BE in a volunteer population.

METHODS

Upper endoscopy (EGD) was performed in 961 persons with no prior history of EGD who were scheduled for colonoscopy. Symptom questionnaires were completed prior to endoscopy. Biopsy specimens were taken from the gastric cardia and any columnar mucosa extending > or =5 mm into the tubular esophagus and from the stomach for H. pylori infection in the last 812 patients.

RESULTS

The study sample was biased toward persons undergoing colonoscopy, males, and persons with upper GI symptoms. The prevalence of BE was 65 of 961 (6.8%) patients, including 12 (1.2%) with long-segment BE (LSBE). Among 556 subjects who had never had heartburn, the prevalences of BE and LSBE were 5.6% and 0.36%, respectively. Among 384 subjects with a history of any heartburn, the prevalences of BE and LSBE were 8.3% and 2.6%, respectively. In a univariate analysis, LSBE was more common in those with any heartburn vs. those with no heartburn (P = 0.01), but the sample size was insufficient to allow multivariate analysis of predictors of LSBE. In a multivariate analysis, BE was associated with increasing age (P = 0.02), white race (P = 0.03), and negative H. pylori status (P = 0.04). Overall, BE was not associated with heartburn, although heartburn was more common in persons with LSBE or circumferential short segments.

CONCLUSIONS

LSBE is very uncommon in patients who have no history of heartburn. SSBE is relatively common in persons age > or =40 years with no prior endoscopy, irrespective of heartburn history.

Impact of antireflux operation on columnar-lined esophagus

BACKGROUND

The effect of antireflux operation on the natural history of columnar-lined esophagus (CLE) is not fully understood. The aim of this study was to assess a single center's experience and review the literature on the impact of antireflux operation on CLE without high-grade dysplasia.

STUDY DESIGN

The medical records of 26 patients with CLE but without high-grade dysplasia who underwent antireflux operation in our unit were retrospectively analyzed at longterm followup with detailed endoscopic investigation. Thirteen patients presented with intestinal metaplasia (6 had short segments, and 1 had preoperative laser ablation) and 13 without intestinal metaplasia. For the group of 13 patients presenting with intestinal metaplasia, the mean endoscopic followup was 74.7 months (median 46 months). Three of six with short-segment lesion and two of seven with circumferential involvement had complete regression of intestinal metaplasia (one after laser therapy). None had progression to dysplasia or carcinoma.

RESULTS

For the group of 13 patients without intestinal metaplasia, mean endoscopic followup was 43.9 months (median 28 months). One had complete regression of CLE, and none developed intestinal metaplasia during surveillance.

CONCLUSIONS

Our study suggests that antireflux operation can alter the natural history of CLE, allowing disease stabilization in a substantial proportion of patients. After antireflux operation, total regression of CLE is possible, but in an unpredictable manner.

Hiatal hernia size, Barrett's length, and severity of acid reflux are all risk factors for esophageal adenocarcinoma

OBJECTIVE

The reasons for the development of dysplasia and adenocarcinoma in Barrett's mucosa are not well understood. The aims of this study were to characterize risk factors for the transition from Barrett's esophagus without dysplasia to Barrett's esophagus with high-grade dysplasia or esophageal adenocarcinoma.

METHODS

A group of 131 patients with high-grade dysplasia or esophageal adenocarcinoma were selected as case subjects. A first population of 2170 patients without gastroesophageal reflux disease (GERD) and a second population of 1189 patients with Barrett's esophagus served as two control groups. Logistic regression analyses were used to compare the risk factors associated with the occurrence of high-grade dysplasia or esophageal adenocarcinoma.

RESULTS

Patients with high-grade dysplasia or esophageal adenocarcinoma shared many characteristics with other forms of severe GERD, such as older age, male gender, and white ethnicity. The length of Barrett's esophagus and the size of hiatus hernia increased the risk for both conditions. Subjects with high-grade dysplasia and adenocarcinoma had more severe acid reflux than patients with other forms of GERD. Smoking and alcohol consumption did not affect the risk for developing high-grade dysplasia or adenocarcinoma in patients with Barrett's esophagus.

CONCLUSIONS

High-grade dysplasia and esophageal adenocarcinoma seem to stem from an extreme and unfavorable constellation of all risk factors that are generally held responsible for the development of GERD and Barrett's esophagus.

Barrett's esophagus: clinical characteristics

Barrett's metaplasia develops in 6-14% of individuals with gastroesophageal reflux. Barrett's adenocarcinomas are increasing in epidemic proportions for as yet unknown reasons, approximately 0.5-1% of patients with Barrett's will develop adenocarcinoma. Heartburn duration and frequency (but not severity), male gender, and Caucasian race are major risk factors for developing cancer. Obesity and smoking are weak risk factors. Survival is determined by depth of tumor invasion (stage). Once invasion of the muscularis propia occurs, the vast majority of patients will have developed widespread metastasis, even when clinical staging studies are negative. No currently available therapy results in prolonged survival once metastases develop. Thus, the more widespread use of effective surveillance strategies is the only currently available means for reducing the morbidity and mortality associated with Barrett's adenocarcinoma.

Rationale for surgical therapy of Barrett esophagus

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.

Barrett's oesophagus: diagnosis and management

Gastro-oesophageal reflux disease and its sequela, Barrett's oesophagus, are the major recognized risk factors for oesophageal adenocarcinoma, a tumour whose frequency has increased dramatically in Western countries over the past few decades. Barrett's oesophagus develops through the process of metaplasia in which one adult cell type replaces another. The metaplastic, intestinal-type cells of Barrett's oesophagus are predisposed to develop genetic changes that eventuate in cancer. This report reviews the recent controversy regarding diagnostic criteria for Barrett's oesophagus, and provides practical guidelines for identifying the condition. The risks and benefits of the proposed medical, surgical and endoscopic therapies for Barrett's oesophagus are discussed in detail, and the approach to management recently endorsed by the American College of Gastroenterology is summarized.

Effect of segment length on risk for neoplastic progression in patients with Barrett esophagus

BACKGROUND

The increased risk for esophageal adenocarcinoma associated with long-segment (> or =3 cm) Barrett esophagus is well recognized. Recent studies suggest that short-segment (<3 cm) Barrett esophagus is substantially more common; however, the risk for neoplastic progression in patients with this disorder is largely unknown.

OBJECTIVE

To examine the relation between segment length and risk for aneuploidy and esophageal adenocarcinoma in patients with Barrett esophagus.

DESIGN

Prospective cohort study.

SETTING

University medical center in Seattle, Washington.

PATIENTS

309 patients with Barrett esophagus.

MEASUREMENTS

Patients were monitored for progression to aneuploidy and adenocarcinoma by repeated endoscopy with biopsy for an average of 3.8 years. Cox proportional hazards analysis was used to calculate adjusted relative risks and 95% Cls.

RESULTS

After adjustment for histologic diagnosis at study entry, segment length was not related to risk for cancer in the full cohort (P > 0.2 for trend). When patients with high-grade dysplasia at baseline were excluded, however, a nonsignificant trend was observed; based on a linear model, a 5-cm difference in segment length was associated with a 1.7-fold (95% CI, 0.8-fold to 3.8-fold) increase in cancer risk. Among all eligible patients, a 5-cm difference in segment length was associated with a small increase in the risk for aneuploidy (relative risk, 1.4 [CI, 1.0 to 2.1]; P = 0.06 for trend). A similar trend was observed among patients without high-grade dysplasia at baseline.

CONCLUSIONS

The risk for esophageal adenocarcinoma in patients with short-segment Barrett esophagus was not substantially lower than that in patients with longer segments. Although our results suggest a small increase in risk for neoplastic progression with increasing segment length, additional follow-up is needed to determine whether the patterns of risk occurred by chance or represent true differences. Until more data are available, the frequency of endoscopic surveillance should be selected without regard to segment length.

Columnar mucosa and intestinal metaplasia of the esophagus: fifty years of controversy

OBJECTIVE

To outline current concepts regarding etiology, diagnosis, and treatment of intestinal metaplasia of the esophagus and cardia.

SUMMARY BACKGROUND DATA

Previously, endoscopic visualization of columnar mucosa extending a minimum of 3 cm into the esophagus was sufficient for the diagnosis of Barrett's esophagus, but subsequently the importance of intestinal metaplasia and the premalignant nature of Barrett's have been recognized. It is now apparent that shorter lengths of intestinal metaplasia are common, and share many features of traditional 3-cm Barrett's esophagus.

METHODS

Themes and concepts pertaining to intestinal metaplasia of the esophagus and cardia are developed based on a review of the literature published between 1950 and 1999.

RESULTS

Cardiac mucosa is the precursor of intestinal metaplasia of the esophagus. Both develop as a consequence of gastroesophageal reflux. Intestinal metaplasia, even a short length, is premalignant, and the presence of dysplasia indicates progression on the pathway to adenocarcinoma. Antireflux surgery, as opposed to medical therapy, may induce regression or halt progression of intestinal metaplasia. The presence of high-grade dysplasia is frequently associated with an unrecognized focus of adenocarcinoma. Vagal-sparing esophagectomy removes the diseased esophagus and is curative in patients with high-grade dysplasia. Invasion beyond the mucosa is associated with a high likelihood of lymph node metastases and requires lymphadenectomy.

CONCLUSIONS

Despite improved understanding of this disease, controversy about the definition and best treatment of Barrett's esophagus continues, but new molecular insights, coupled with careful patient follow-up, should further enhance knowledge of this disease.

Barrett's esophagus. Reducing the risk of progression to adenocarcinoma

Barrett's metaplasia develops in 6% to 14% of individuals with gastroesophageal reflux. Barrett's adenocarcinomas are increasing in epidemic proportions for, as yet unknown, reasons; approximately 0.5% to 1% of patients with Barrett's metaplasia develop adenocarcinoma. Heartburn duration and frequency (but not severity), male gender, and white race are major risk factors for developing cancer. Obesity and smoking are weak risk factors. Survival is determined by depth of tumor invasion (stage). Once invasion of the muscularis propria occurs, most patients have developed widespread metastasis, even when clinical staging studies are negative. No currently available therapy results in prolonged survival once metastases develop. Thus, the more widespread use of effective surveillance strategies is the only currently available means for reducing the morbidity and mortality associated with Barrett's adenocarcinoma.

Results of the Collis-Nissen gastroplasty in patients with Barrett's esophagus

BACKGROUND

Barrett's esophagus (BE) is an advanced stage of gastroesophageal reflux disease. Medical treatment and standard antireflux operations show a high failure rate. An elongated gastroplasty, wrapped by a total fundoplication should provide a tension-free repair with adequate protection against reflux. The aim of this study is to review the operative effects of a Collis-Nissen gastroplasty to treat reflux in Barrett's esophagus.

METHODS

From January 1989 to December 1997, 45 patients with BE (38 men, 7 women) aged 53.5 years, underwent a Collis-Nissen gastroplasty. Mean follow-up is 35.9 months (range, 6 to 110 months). Pre- and postoperative evaluations included symptom assessment, esophagogram, endoscopy, manometry, 24-hour pH study, and esophageal emptying scintigrams.

RESULTS

There were no operative deaths. All reflux symptoms were controlled. Acid reflux was significantly reduced (percent time exposure decreased from 10% to 1%) and lower esophageal sphincter (LES) pressure were restored to normal (LES gradient increased from 4 mm Hg to 11 mm Hg). LES incomplete relaxation was noted in 50% of patients postoperatively. Endoscopically, mucosal damage from reflux healed but the columnar mucosa with intestinal metaplasia persisted.

CONCLUSIONS

The Collis-Nissen gastroplasty, in patients with BE, controls reflux disease, its symptoms, and the mucosal damage associated with this condition. It restores the LES gradient but increases the resistance to bolus transit. There is no regression of the abnormal mucosa despite reflux control.

Barrett's esophagus

The columnar replacement of squamous epithelium in the lower esophagus is the result of gastroesophageal reflux. Whether the squamous cells are replaced or undergo metaplasia is still conjectural. This neoepithelium is unstable in the presence of continued reflux and prone to complications of stricture, ulceration, and adenocarcinoma. Considerable evidence supports the hypothesis that duodenal contents play a role in the development of Barrett's esophagus and its complications. The increasing incidence of adenocarcinoma in Barrett's esophagus is of concern in the Western World. Surveillance programs in some centers have been successful in early diagnosis, and excellent survival periods have been reported following resection in these cases. Both medical and surgical antireflux treatment is successful in symptom relief, but even in the absence of symptoms, reflux may continue. Surgery offers better overall results than proton pump inhibition of gastric acid and has been more popular since less aggressive (minimally invasive) techniques have been popularized. Mucosal ablation and antireflux measures by medicine or surgery are still in the experimental stages but hold considerable promise for the future.

The columnar-lined esophagus. History, terminology, and clinical issues

Recently, there has been intense controversy regarding diagnostic criteria for Barrett's esophagus. Some authorities have defined the condition according to an arbitrary extent of esophageal columnar lining, whereas others have felt that the presence of specialized intestinal metaplasia anywhere in the esophagus establishes the diagnosis. This article discusses the problems that arise when either of these diagnostic approaches are used and proposes an alternative classification system for the columnar-lined esophagus.

Epidemiology and molecular biology of Barrett's adenocarcinoma

In the United States, the incidence of esophageal adenocarcinoma has risen faster than any other malignancy in recent years, and now represents the most common histologic type of esophageal cancer observed in major institutions. The precise etiology of this malignancy, and the epidermiologic variables responsible for its dramatically rising incidence, remains obscure. Elucidation of the molecular biology of malignant transformation in Barrett's esophagus may improve the management of patients with advanced esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinogenesis may facilitate early detection of occult carcinomas, and enable therapeutic interventions designed to prevent these otherwise highly lethal neoplasms.

Extent of Barrett's metaplasia: a prospective study of the serial change in area of Barrett's measured by quantitative endoscopic imaging

BACKGROUND

An accurate determination of the extent of Barrett's metaplasia is critical to the study of its natural history and response to therapy. Our hypothesis is that area calculations offer advantages over length estimates of Barrett's.

METHODS

Changes in both measures and estimates of progression or regression between two endoscopies in 17 patients were compared. Area was calculated using a computer image analysis technique.

RESULTS

Although there was no significant difference in length correlation versus area correlation between endoscopies (r = 0.90 vs 0.99), the mean change in absolute length (1.4 +/- 0.2 cm) was greater than the change in area (4.5 +/- 1.4 cm2, equivalent to a length of 0.67 +/- 0.2 cm, p = 0.001). The percent change in absolute length (26.9%) was greater than the change in area (16%, p = 0.001). Discordance of estimates of progression or regression between area and length was found in nine patients. The image technique detected no change in the area of squamous islands.

CONCLUSIONS

Imaging analysis can precisely measure the extent of Barrett's including squamous islands. Area showed little change, whereas measures of length were more varied. Computer based image analysis provides a more precise estimate of interval change of Barrett's.

Barretts's esophagus: does an antireflux procedure reduce the need for endoscopic surveillance?

Barrett's esophagus, a premalignant condition associated with chronic gastroesophageal reflux, carries an approximate 40-fold increase in the incidence of adenocarcinoma. Between 1975 and 1994, 113 patients with Barrett's esophagus underwent antireflux procedures at the Mayo Clinic. The antireflux procedure was performed more than 3 months after the diagnosis of Barrett's disease in 39 patients (34.5%) and during the initial preoperative evaluation in 74 (65.5%). Uncut Collis-Nissen fundoplication was performed in 69 patients (61.1%), Nissen fundoplication was performed in 16 (14.2%), cut Collis-Nissen fundoplication was performed in 12 (10.6%), Belsey repair was performed in nine (8.0%), Collis-Belsey repair was performed in six (5.3%), and Nissen fundoplication with an anterior gastropexy was performed in one (0.9%). There was one operative death (0.9% mortality). Morbidity occurred in 41 patients (36.3%), including cardiac arrhythmia in eight (7.0%), pneumonia in six (5.3%), empyema in five (4.4%), hemorrhage in four (3.6%), myocardial infarction in two (1.8%), and wound dehiscence, wound infection, perforated duodenal ulcer, and postoperative leak in one each (0.9%). Median follow-up for the 112 survivors of operation was 6.5 years (range 4 months to 18.2 years). Excellent or good alleviation of symptoms was obtained in 92 patients (82.2%). Ninety-nine patients (88.4%) are currently alive and 13 (11.6%) have died. Three patients (2.7%) subsequently had adenocarcinoma of the esophagus after the antireflux procedure at 13, 25, and 39 months; two of these died of cancer. The incidence of esophageal carcinoma in this select group of patients was one in 273.8 patient-years of follow-up. We conclude that although antireflux procedures in patients with Barrett's esophagus result in long-term control of reflux symptoms, the possibility of esophageal cancer still exists. Endoscopic surveillance should therefore be recommended.

Risk factors for the development of an adenocarcinoma in columnar-lined (Barrett) esophagus. The Rotterdam Esophageal Tumor Study Group

BACKGROUND

To evaluate the importance of the length of columnar-lined esophagus, sex, age, smoking, and drinking habits as risk factors for malignant degeneration, the authors performed a retrospective case-control study comparing patients with and without adenocarcinoma in Barrett esophagus.

METHODS

The records of 96 patients (53 male and 43 female; mean age, 61 years) with a benign columnar-lined esophagus and 62 patients (47 male and 15 female; mean age, 62 years) with an adenocarcinoma in columnar-lined esophagus referred to the Rotterdam Esophageal Tumor Study Group, diagnosed over the same period (1978-1985), were reviewed. A frequency distribution of the length of columnar-lined esophagus in both groups was made. Statistical analysis was performed with multivariate methods.

RESULTS

The length of columnar-lined esophagus was related significantly to carcinoma: a doubling of the length resulted in a 1.7 times increased risk. Smokers had a 2.3-fold increased risk as compared with nonsmokers. Male sex as a risk factor approached statistical significance (P = 0.06). Adjusted for these risk factors, no relation between carcinoma and age or alcohol consumption was found.

CONCLUSIONS

The risk of development of an adenocarcinoma in Barrett esophagus increased with the length of Barrett epithelium. Smoking and possibly male sex were also risk factors. The identification of these risk factors may help in developing more efficient screening programs for patients with Barrett esophagus.

Current concepts concerning the nature and treatment of Barrett's esophagus and its complications

Current concepts regarding the nature and the treatment of Barrett's esophagus and its complications are reviewed. The columnar-lined lower esophagus is being increasingly recognized as an acquired condition caused by gastroesophageal reflux. Many patients are asymptomatic. Barrett's esophagus occurs in about 10% to 15% of patients with reflux esophagitis. The diagnosis depends on endoscopy and biopsy. Complications are common and include ulceration, stricture, dysplasia, and adenocarcinoma. Esophagitis, ulceration, and stricture can usually be treated medically. Surgical approaches are discussed for patients whose condition is refractory to medical therapy. The premalignant nature of Barrett's epithelium is well recognized, and strategies for surveillance and resection are discussed. Survival after resection of adenocarcinoma in Barrett's esophagus is not appreciably different from that of other carcinomas. Surveillance with endoscopy offers the best chance for early detection and cure.

Persistence of Barrett's esophagus in children after antireflux surgery: influence on follow-up care

Adenocarcinoma arising in Barrett's esophagus has recently been described in two children aged 11 and 14 years. The long-term follow-up of Barrett's esophagus in children is not well described. We evaluated 16 cases of Barrett's esophagus in children treated at this institution during the last 16 years. Ages ranged from 1.2 to 16 years (mean, 10.3 years). There were 11 boys and 5 girls. Barrett's esophagus was documented by endoscopy in 14 instances and at autopsy in 2 patients with secretory diarrhea and tetralogy of Fallot who died of sepsis. Two children had cancer (neuroblastoma, leukemia) and died of their malignant disease. Five patients had cerebral palsy, 1 esophageal atresia, 1 Fanconi's anemia, and 5 were otherwise normal children. Six were treated medically. Eight patients underwent Nissen fundoplication for complications of gastroesophageal reflux (GER). Five patients were available for follow-up endoscopy (mean, 2 years; range, 1.1 to 5.4 years). Endoscopy was performed on a yearly basis, obtaining biopsy specimens from multiple levels of the esophagus. Four children had satisfactory clinical response to an antireflux procedure including the resolution of a stricture in one case. However, in all 5 cases persistent metaplastic epithelium was documented and showed no evidence of regression. Although there has been speculation that Barrett's esophagus in children may be more likely to revert to normal squamous epithelium than in the adult, there has been only one case of regression in 180 cases of Barrett's esophagus occurring in children described in 37 reports in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinomas arising in tongues or short segments of Barrett's esophagus

The diagnosis of Barrett's esophagus is established when the esophageal mucosa is lined by 2-3 cm of columnar epithelium or when specialized (intestinal type) columnar epithelium of any length is present. Emphasis is frequently placed on long segments of Barrett's because these patients reportedly are at higher risk of developing adenocarcinoma than patients with shorter segments. We present four cases of adenocarcinoma that arose in tongues or short segments (less than 2 cm) of specialized columnar epithelium near the gastroesophageal junction. We emphasize the need for biopsy of minimal appearing abnormalities in this area, and we suggest that histologic subtype, rather than length of involvement, be the major criterion for establishment of Barrett's esophagus.

Barrett's esophagus. A continuing conundrum

Barrett's esophagus, a condition in which the distal esophagus is lined by columnar epithelium, is almost always caused by gastroesophageal reflux and often occurs in conjunction with a sliding hiatal hernia. Patients are typically white men in their 50s who smoke and drink, and they present with complaints of regurgitation, heartburn, and/or dysphagia. Endoscopic biopsies are required to confirm the diagnosis. Complications, such as stricture, ulcer, dysplasia, and malignant degeneration, occur in many cases. Adenocarcinoma is the most serious complication. Medical treatment, including life-style changes as well as pharmacologic therapy, usually relieves symptoms and heals esophagitis, but when it fails, antireflux surgery is indicated. Patients without evidence of dysplasia should undergo endoscopy yearly; those with mild dysplasia require more frequent surveillance. If biopsies disclose severe dysplasia, esophagogastrectomy should be performed.

Effect of antireflux operation on Barrett's mucosa

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined as histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett's esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.

Adenocarcinoma in Barrett's oesophagus: an overrated risk

Barrett's oesophagus is a risk factor for the development of oesophageal cancer and for this reason annual endoscopic surveillance has been proposed. In this retrospective study of all patients with Barrett's oesophagus diagnosed in a 12 year period carcinoma had developed in only four patients. The incidence of oesophageal cancer in this series was one in 170 patient years, which means a 30-fold increase compared with the general population. The survival of patients with Barrett's oesophagus was not different, however, from an age and sex matched control population. It is concluded that systematic endoscopic surveillance of patients with Barrett's oesophagus is not indicated.

Oesophageal carcinoma: endoscopic and clinical findings in 258 patients

During the 10-year period 1971-1980, oesophagoscopy was carried out on a total of 3235 patients in the Department of Otolaryngology, Turku University Central Hospital, Finland. Oesophageal carcinoma was diagnosed in 258 patients, 113 (44 per cent) men and 145 (56 per cent) women. The diagnosis was verified in 228 cases (88.4 per cent) by using an optical rigid oesophagoscope and in 30 cases (11.6 per cent) by a fibreoptic endoscope. The most common and earliest symptom was difficulty in swallowing in 50 per cent of cases. In 44 per cent of patients the symptoms persisted over six months before diagnosis. Upper and middle thoracic portions of the oesophagus were the sites of origin of the carcinoma in 57 per cent of the patients. The macroscopic picture obtained by oesophagoscopy was regarded as malignant in 83 per cent of patients and extraoesophageal spread of the tumour was estimated to be present in 48 per cent of patients by the time of diagnosis. Histological studies showed the tumour to be squamous cell carcinoma in 62 per cent of patients and in 24 per cent well differentiated. Squamous cell carcinoma was seen more often in men than in women. In patients with carcinoma in situ, alcohol and tobacco were regarded as aetiological factors in 53 per cent of cases. The need for repeated oesophagoscopy in patients with symptoms related to swallowing is stressed.

Management of adenocarcinoma in a columnar-lined esophagus

Of 89 patients diagnosed between 1973 and 1983 as having at least 3 cm of columnar-lined esophagus, 22 were found to have adenocarcinoma. There was no difference in sex ratio, smoking, or the use of alcohol between the benign and adenocarcinoma groups. The patients with adenocarcinoma were older (63 years versus 57 years) and had a higher frequency of dysphagia (64% versus 46%), gastrointestinal bleeding (36% versus 24%), extended columnar-lined esophagus (94% versus 28%), and epithelial dysplasia (68% versus 10%). Heartburn was less frequent in the adenocarcinoma group (59% versus 79%), but when it occurred, it was of longer duration (mean, 18.8 years versus 10.9 years). In 2 patients, progression from benign columnar-lined esophagus to early adenocarcinoma was observed. Of the patients with adenocarcinoma, 2 received palliative treatment without resection and died four and nine months later. Six underwent partial esophagogastrectomy with 1 postoperative death. Four had residual columnar-lined esophagus at the resection margins. In one of them, stricture developed and in one, anastomotic recurrence of adenocarcinoma; 1-year survival was 50%. Fourteen patients underwent total thoracic esophagectomy with no operative deaths, strictures, or anastomotic recurrences; 1-year survival was 5 of 6. Surgical staging revealed that 63% had transmural spread and 55%, lymph node involvement.(ABSTRACT TRUNCATED AT 250 WORDS)

Barrett's oesophagus

The bulk of available evidence supports the view that Barrett's oesophagus is an acquired condition due to chronic gastro-oesophageal reflux. It is possible that a few cases are congenital. Barrett's oesophagus gives rise to severe stricture and ulceration and has a significant malignant potential. Treatment is designed to prevent reflux and, if possible, to reverse the metaplastic change. Dysplasia is of ominous significance and requires frequent careful surveillance.

Analysis of adenocarcinoma in Barrett's esophagus utilizing a staging system

Based on a retrospective review of nine patients with adenocarcinoma in a Barrett's esophagus and the reports of similar cases in the literature, a staging system for this malignancy was devised. A progression of changes could be identified that corresponded to the stages. These changes consisted of dysplasia progressing to carcinoma in situ and invasive malignancy with metastases. Stage III disease carried the same grim prognosis as a similar stage of squamous cell carcinoma of the esophagus. Earlier stages of adenocarcinoma of the esophagus appeared to have a better prognosis. White men with symptoms of reflux esophagitis, esophageal strictures, and/or hiatal hernias who have Barrett's esophagus extending proximal to the distal 10 cm of the esophagus appear to have a propensity to develop adenocarcinoma of the esophagus. Consideration should be given to antireflux surgery and close follow-up by periodic esophagoscopy and biopsy of the esophagus in these patients. If neoplasia is found, the thoracic esophagus should be totally removed with the stomach or left colon anastomosed to the cervical esophagus. Because of the poor prognosis of Stage III disease, postoperative chemotherapy should be considered.