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Medina B, Molena D. Reflux, Barrett's Esophagus, and Esophageal Adenocarcinoma After Bariatric Surgery. FOREGUT (THOUSAND OAKS, CALIF.) 2021; 1:393-400. [PMID: 38646141 PMCID: PMC11031263 DOI: 10.1177/26345161211068367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
We present the case of a patient who developed esophageal adenocarcinoma after a previous laparoscopic sleeve gastrectomy. Bariatric surgery has emerged as the most effective treatment option for weight loss and obesity-related diseases; however, sleeve gastrectomy promotes gastroesophageal reflux and leads to Barrett's esophagus in a substantial portion of patients. The natural history of Barrett's esophagus in these patients is unknown, and active surveillance is recommended until the incidence of dysplasia and adenocarcinoma in this population is clarified. Management options for these patients include conversion to Roux-en-Y gastric bypass. Although esophagectomy in patients who have previously undergone sleeve gastrectomy may require an alternative conduit, the remnant stomach can be used in carefully selected patients. Here, we review the different weight loss procedures, their effect on gastroesophageal reflux disease and Barrett's esophagus, and the treatment options for patients with esophageal cancer after sleeve gastrectomy. We report the use of preoperative coil embolization as a means of vascular preconditioning before successful use of a gastric conduit.
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2
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Panda A, Shin MR, Cheng C, Bajpai M. Barrett's Epithelium to Esophageal Adenocarcinoma: Is There a "Point of No Return"? Front Genet 2021; 12:706706. [PMID: 34603373 PMCID: PMC8485939 DOI: 10.3389/fgene.2021.706706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Esophageal adenocarcinoma (EA) arises from Barrett's epithelium (BE), and chronic gastroesophageal reflux disease is considered the strongest risk factor for disease progression. All BE patients undergo acid suppressive therapy, surveillance, and BE removal by surgery or endoscopic ablation, yet the incidence of EAC continues to increase. Despite the known side effects and mortality, the one-size-fits-all approach is the standard clinical management as there are no reliable methods for risk stratification. Methods: Paired-end Illumina NextSeq500 RNA sequencing was performed on total RNA extracted from 20-week intervals (0, 20, 40, and 60 W) of an in vitro BE carcinogenesis (BEC) model to construct time series global gene expression patterns (GEPs). The cells from two strategic time points (20 and 40 W) based on the GEPs were grown for another 20 weeks, with and without further acid and bile salt (ABS) stimulation, and the recurrent neoplastic cell phenotypes were evaluated. Results: Hierarchical clustering of 866 genes with ≥ twofold change in transcript levels across the four time points revealed maximum variation between the BEC20W and BEC40W cells. Enrichment analysis confirmed that the genes altered ≥ twofold during this window period associated with carcinogenesis and malignancy. Intriguingly, the BEC20W cells required further ABS exposure to gain neoplastic changes, but the BEC40W cells progressed to malignant transformation after 20 weeks even in the absence of additional ABS. Discussion: The transcriptomic gene expression patterns in the BEC model demonstrate evidence of a clear threshold in the progression of BE to malignancy. Catastrophic transcriptomic changes during a window period culminate in the commitment of the BE cells to a "point of no return," and removal of ABS is not effective in preventing their malignant transformation. Discerning this "point of no return" during BE surveillance by tracking the GEPs has the potential to evaluate risk of BE progression and enable personalized clinical management.
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Affiliation(s)
- Anshuman Panda
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Mi Ryung Shin
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Christina Cheng
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Manisha Bajpai
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
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3
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Fedorova E, Watson TJ. Antireflux and Endoscopic Therapies for Barrett Esophagus and Superficial Esophageal Neoplasia. Surg Clin North Am 2021; 101:391-403. [PMID: 34048760 DOI: 10.1016/j.suc.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Barrett esophagus (BE), defined as intestinal metaplasia of the distal esophageal mucosa, typically results from chronic gastroesophageal reflux disease and is the only known precursor of esophageal adenocarcinoma. The standard of care for the management of early esophageal neoplasia in the setting of BE has changed drastically over the past 15 years. Further investigation into diagnostic and therapeutic adjuncts will continue to improve our ability to control or cure BE before its advancement to a life-threatening malignancy.
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Affiliation(s)
- Ekaterina Fedorova
- MedStar Franklin Square Medical Center, 9000 Franklin Square Drive, Department of Surgery, Baltimore, MD 21237, USA
| | - Thomas J Watson
- MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, 4PHC Department of Surgery, Washington, DC 20007, USA.
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Johnson MK, Venkatesh M, Liu N, Breuer CR, Shada AL, Greenberg JA, Lidor AO, Funk LM. pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery. J Gastrointest Surg 2021; 25:28-35. [PMID: 33111260 PMCID: PMC7855403 DOI: 10.1007/s11605-020-04831-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.
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Affiliation(s)
- Morgan K Johnson
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Natalie Liu
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Catherine R Breuer
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Amber L Shada
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Anne O Lidor
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Luke M Funk
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
- William S. Middleton Memorial VA Hospital, Madison, WI, USA.
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Adil MT, Al-Taan O, Rashid F, Munasinghe A, Jain V, Whitelaw D, Jambulingam P, Mahawar K. A Systematic Review and Meta-Analysis of the Effect of Roux-en-Y Gastric Bypass on Barrett's Esophagus. Obes Surg 2020; 29:3712-3721. [PMID: 31309524 DOI: 10.1007/s11695-019-04083-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obesity is associated with a twofold risk of gastroesophageal reflux disease (GERD) and thrice the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) leads to weight loss and improvement of GERD in population with obesity, but its effect on BE is less clear. METHODS Bibliographic databases were searched systematically for relevant articles till January 31, 2019. Studies evaluating the effect of RYGB on BE with preoperative and postoperative endoscopy and biopsy were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was conducted using Mantel-Haenszel, random effects model and presented as risk difference (RD) or odds ratio (OR) with 95% confidence intervals. RESULTS Eight studies with 10,779 patients undergoing RYGB reported on 117 patients with BE with follow-up of > 1 year. Significant regression of BE after RYGB was observed (RD - 0.56.95% c.i. - 0.69 to - 0.43; P < 0.001). Subgroup analysis showed regression of both short-segment BE [ssBE] (RD - 0.51.95% c.i. - 0.68 to - 0.33; P < 0.001) and long-segment BE [lsBE] (RD - 0.46.95% c.i. - 0.71 to - 0.21; P < 0.001). RYGB also caused improvement in GERD in patients of BE (RD - 0.93, 95% c.i. - 1.04 to - 0.81; P < 0.001). RYGB was strongly associated with regression of BE compared with progression (OR 31.2.95% c.i. 11.37 to 85.63; P < 0.001). CONCLUSIONS RYGB leads to significant improvement of BE at > 1 year after surgery in terms of regression and resolution of the associated GERD. Both ssBE and lsBE improve after RYGB significantly.
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Affiliation(s)
- Md Tanveer Adil
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom.
| | - Omer Al-Taan
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Farhan Rashid
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Aruna Munasinghe
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Vigyan Jain
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Douglas Whitelaw
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Periyathambi Jambulingam
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Kamal Mahawar
- Department of General Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, United Kingdom
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Bonavina L, Fisichella PM, Gavini S, Lee YY, Tatum RP. Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients. Ann N Y Acad Sci 2020; 1481:117-126. [PMID: 32266986 DOI: 10.1111/nyas.14350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/14/2022]
Abstract
In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milano, Italy
| | - P Marco Fisichella
- Department of Surgery, Northwestern University, Feinberge School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, Washington
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DeMeester SR. Laparoscopic Hernia Repair and Fundoplication for Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:309-324. [PMID: 32146948 DOI: 10.1016/j.giec.2019.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Antireflux surgery is challenging, and has become even more challenging with the introduction of alternative endoscopic and laparoscopic options for patients with gastroesophageal reflux disease (GERD). The Nissen fundoplication remains the gold standard for the durable relief of GERD symptoms and esophagitis. All antireflux procedures have a failure rate, and it is important to minimize factors that are associated with failure. The selection of patients for antireflux surgery as well as the choice of the procedure requires a thorough understanding of esophageal physiology and the pros and cons of various options.
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Affiliation(s)
- Steven R DeMeester
- Thoracic and Foregut Surgery, General and Minimally Invasive Surgery, The Oregon Clinic, 4805 Northeast Glisan Street, Suite 6N60, Portland, OR 97213, USA.
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9
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Walle KV, Funk LM, Xu Y, Davies KD, Greenberg J, Shada A, Lidor A. Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication. J Surg Res 2018; 235:52-57. [PMID: 30691837 DOI: 10.1016/j.jss.2018.09.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/06/2018] [Accepted: 09/11/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Laparoscopic fundoplication is the gold standard operation for treatment of gastroesophageal reflux disease (GERD). It has been suggested that persistent postoperative dysphagia is increased following Nissen fundoplication compared to partial fundoplication. This study aimed to determine risk factors for persistent postoperative dysphagia, specifically examining the type of fundoplication. METHODS Patients experiencing GERD symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication from 2009 to 2016 were identified from a single-institutional database. A dysphagia score was obtained as part of the GERD health-related quality of life questionnaire. Persistent dysphagia was defined as a difficulty swallowing score ≥1 (noticeable) on a scale from 0 to 5 at least 1 y postoperatively. Odds ratios of persistent dysphagia among those who underwent antireflux surgery were calculated in a multivariate logistic regression model adjusted for fundoplication type, sex, age, body mass index, and redo operation. RESULTS Of the 441 patients who met inclusion criteria, 255 had ≥1 y of follow-up (57.8%). The median duration of follow-up was 3 y. In this cohort, 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n = 66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen versus partial) and the likelihood of postoperative dysphagia. CONCLUSIONS Persistent postoperative dysphagia after antireflux surgery occurred in approximately one-quarter of patients and did not differ by the type of fundoplication. These findings suggest that both Nissen and partial fundoplication are reasonable choices for an antireflux operation for properly selected patients.
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Affiliation(s)
- Kara Vande Walle
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Luke M Funk
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin; Department of Surgery, William S. Middleton VA, Madison, Wisconsin
| | - Yiwei Xu
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Kevin D Davies
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Jacob Greenberg
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Amber Shada
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin
| | - Anne Lidor
- Department of Surgery, University of Wisconsin-Madison, Clinical Science Center, Madison, Wisconsin.
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Steinemann DC, Müller PC, Schwarz AC, Zerz A, Linke GR, Müller-Stich BP. Feasibility and effectiveness of laparoscopic transgastric stapler-assisted circumferential esophageal mucosectomy and simultaneous fundoplication in a pig model. Dis Esophagus 2018; 31:5000037. [PMID: 29788275 PMCID: PMC6124652 DOI: 10.1093/dote/doy030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic transgastric stapler-assisted mucosectomy (SAM) has been described for minimally invasive circumferential en bloc resection of Barrett's esophagus (BE). Conceivably long-term disease control might be achieved by adding antireflux surgery after resection of BE by SAM. The aim of this study was to assess the feasibility of combined SAM and fundoplication in one laparoscopic procedure in six pigs. Furthermore, the competence of the gastroesophageal junction (GEJ) was assessed at baseline, after SAM, and after subsequent laparoscopic fundoplication. At each measuring point reflux measurements were repeated 6 times in each pig. Blue-colored water was infused into the stomach to provoke reflux. Intragastric yield pressure and volume were recorded until drainage of blue solution (DBS) was noted. Time to reflux was measured by DBS and by multichannel intraluminal impedance (MII). In all animals SAM followed by laparoscopic fundoplication was feasible in a single session. A weakening of the GEJ was found after SAM, indicated by decreased yield pressure (11.5 mmHg vs. 8.5 mmHg; P < 0.001), time to DBS (90 seconds vs. 60 seconds; P = 0.008) and MII (80 seconds vs. 33 seconds; P < 0.001). After additional Nissen fundoplication the GEJ competence was restored, with measurements returning to baseline values (time to DBS 99 seconds; P = 0.15; MII 76 seconds; P = 0.84). The yield pressure increased from 11.5 mmHg at baseline to 19.7 mmHg after SAM and fundoplication (P < 0.001). Laparoscopic fundoplication and SAM may be combined in a single laparoscopic session. Although the GEJ was weakened after SAM, Nissen fundoplication restored the GEJ as an effective reflux barrier in this experiment. For clinical validation, the results need to be confirmed in a prospective human trial.
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Affiliation(s)
- Daniel C. Steinemann
- Department of General, Visceral and Tranplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany,Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, 4016 Basel, Switzerland
| | - Philip C. Müller
- Department of General, Visceral and Tranplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Anne-Catherine Schwarz
- Department of General, Visceral and Tranplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Andreas Zerz
- Department of Surgery, Klinik Stephanshorn, Brauerstrasse 95, 9016 St. Gallen, Switzerland
| | - Georg R. Linke
- Department of General, Visceral and Tranplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany,Department of Surgery, Hospital STS Thun AG, Krankenhausstrasse 12, 3600 Thun, Switzerland
| | - Beat P. Müller-Stich
- Department of General, Visceral and Tranplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Abstract
BACKGROUND Increasing prevalence of obesity has shown an associated increase in gastroesophageal reflux disease (GERD)-related diseases. Proton pump inhibitor (PPI) therapy has been demonstrated to reduce the incidence of such diseases. The study's aim was to analyze the Clinical Practice Research Datalink (CPRD) to determine factors that increase the propensity of obese patients on PPIs to develop Barrett's esophagus (BE) and esophageal carcinoma. METHOD A case-control population study was carried out, including patients from the CPRD. Clinicopathological factors were extracted for each patient alongside clinical endpoints of GERD, BE, and esophageal carcinoma. Multivariate analysis was utilized to identify factors that increase the propensity to develop BE and esophageal carcinoma. Statistical significance was p < 0.050. RESULTS One hundred sixty five thousand nine hundred twenty nine obese patients on PPI treatment were identified up until July 2017. Median follow-up time was 119.0 months (range 11.3-1397.9 months). In patients with GERD, the following were associated with increased BE risk: age ≥ 60 years (OR = 1.197; p = 0.039), male (OR = 2.209; p < 0.001), H2 antagonists (OR = 1.377; p < 0.001), D2 antagonists (OR = 1.241; p = 0.008), and hiatus hernias (OR = 6.772; p = 0.017). The following were associated with increased risk of esophageal carcinoma: age (OR = 2.831; p = 0.031), male sex (OR = 3.954; p = 0.003), and hiatus hernias (OR = 12.170; p < 0.001). Only D2 antagonists (OR = 2.588; p = 0.002) were associated with increased risk of developing esophageal carcinoma in BE patients. CONCLUSIONS In obese patients on PPI therapy for reflux, higher BMIs were not associated with increased risk of BE or esophageal carcinoma. Males, older patients, and those with hiatus hernias are at increased risk of developing BE and carcinoma. Failure of PPI monotherapy is predictive of future metaplasia and dysplasia.
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12
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Herbella FAM, Schlottmann F, Patti MG. Antireflux Surgery and Barrett's Esophagus: Myth or Reality? World J Surg 2017; 42:1798-1802. [PMID: 29264726 DOI: 10.1007/s00268-017-4394-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It may seem questionable if antireflux surgery still has a role in the management of patients with Barrett's esophagus (BE) in the current era when antireflux surgery is facing a steady decline, obesity is increasing, pharmacologic treatment for gastroesophageal reflux disease (GERD) is in its splendor, and endoscopic techniques are used more frequently. It is questionable if patients with BE should be operated to stop GERD and to prevent cancer. The aim of this study was to determine the role of antireflux surgery in patients with BE. METHODS Literature review. RESULTS The role of antireflux operations is, in fact, very controversial and neglected. BE is a different phenotype of GERD with a distinct pathophysiology linked to severe reflux of bile and acid, due to a marked anatomic disruption of the gastroesophageal barrier. Published series show that a fundoplication adequately controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion antireflux procedure) may prevent esophageal adenocarcinoma. CONCLUSIONS In conclusion, a fundoplication efficiently controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion procedure) may also prevent esophageal adenocarcinoma.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Francisco Schlottmann
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Marco G Patti
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
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13
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Long-term Efficacy of Laparoscopic Antireflux Surgery on Regression of Barrett's Esophagus Using BRAVO Wireless pH Monitoring. Ann Surg 2017; 266:1000-1005. [DOI: 10.1097/sla.0000000000002019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Andrew B, Alley JB, Aguilar CE, Fanelli RD. Barrett’s esophagus before and after Roux-en-Y gastric bypass for severe obesity. Surg Endosc 2017; 32:930-936. [DOI: 10.1007/s00464-017-5768-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/14/2017] [Indexed: 12/17/2022]
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15
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Emken BEG, Lundell LR, Wallin L, Myrvold HE, Engström C, Montgomery M, Malm AR, Lind T, Hatlebakk JG. Effects of omeprazole or anti-reflux surgery on lower oesophageal sphincter characteristics and oesophageal acid exposure over 10 years. Scand J Gastroenterol 2017; 52:11-17. [PMID: 27593706 DOI: 10.1080/00365521.2016.1224378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the effect of anti-reflux surgery (ARS) versus proton pump inhibitor therapy on lower oesophageal sphincter (LOS) function and oesophageal acid exposure in patients with chronic gastro-oesophageal reflux disease (GORD) over a decade of follow-up. MATERIAL AND METHODS In this randomised, prospective, multicentre study we compared LOS pressure profiles, as well as oesophageal exposure to acid, at baseline and at 1 and 10 years after randomisation to either open ARS (n = 137) or long-term treatment with omeprazole (OME) 20-60 mg daily (n = 108). RESULTS Median LOS resting pressure and abdominal length increased significantly and remained elevated in patients operated on with ARS, as opposed to those on OME. The proportion of total time (%) with oesophageal pH <4.0 decreased significantly in both the surgical and medical groups, and was significantly lower after 1 year in patients treated with ARS versus OME. After 10 years, oesophageal acid exposure was normalised in both groups, with no significant differences, and bilirubin exposure was within normal limits. After 10 years, patients with or without Barrett's oesophagus did not differ in acid reflux control between the two treatment options. CONCLUSIONS Open ARS and OME were both effective in normalising acid reflux into the oesophagus even when studied over a period of 10 years. Anatomically and functionally the LOS was repaired durably by surgery, with increased resting pressure and abdominal length.
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Affiliation(s)
| | - Lars R Lundell
- b Department of Surgery , Centre for Digestive Diseases, Karolinska University Hospital, CLINTEC, Karolinska Institutet , Stockholm , Sweden
| | - Lene Wallin
- c Department of Surgery , Glostrup University Hospital , Copenhagen , Denmark
| | - Helge E Myrvold
- d Department of Cancer Research and Molecular Medicine , Norwegian University of Science and Technology , Trondheim , Norway
| | - Cecilia Engström
- e Department of Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | | | - Anders R Malm
- g Formerly of AstraZeneca Gothenburg , Mölndal , Sweden
| | - Tore Lind
- g Formerly of AstraZeneca Gothenburg , Mölndal , Sweden
| | - Jan G Hatlebakk
- a Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Fernández Fernández N, Domínguez Carbajo AB, João Matias D, Rodríguez-Martín L, Aparicio Cabezudo M, Monteserín Ron L, Jiménez Palacios M, Vivas S. [A comparison of medical versus surgical treatment in Barrett's esophagus acid control]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:311-7. [PMID: 26545949 DOI: 10.1016/j.gastrohep.2015.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/24/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Barrett's oesophagus (BE) is an oesophageal injury caused by gastroesophageal acid reflux. One of the main aims of treatment in BE is to achieve adequate acid reflux control. OBJECTIVE To assess acid reflux control in patients with BE based on the therapy employed: medical or surgical. METHODS A retrospective study was performed in patients with an endoscopic and histological diagnosis of BE. Medical therapy with proton pump inhibitors (PPI) was compared with surgical treatment (Nissen fundoplication). Epidemiological data and the results of pH monitoring (pH time <4, prolonged reflux >5min, DeMeester score) were evaluated in each group. Treatment failure was defined as a pH lower than 4 for more than 5% of the recording time. RESULTS A total of 128 patients with BE were included (75 PPI-treated and 53 surgically-treated patients). Patients included in the two comparison groups were homogeneous in terms of demographic characteristics. DeMeester scores, fraction of time pH<4 and the number of prolonged refluxes were significantly lower in patients with fundoplication versus those receiving PPIs (P<.001). Treatment failure occurred in 29% of patients and was significantly higher in those receiving medical therapy (40% vs 13%; P<.001). CONCLUSIONS Treatment results were significantly worse with medical treatment than with anti-reflux surgery and should be optimized to improve acid reflux control in BE. Additional evidence is needed to fully elucidate the utility of PPI in this disease.
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Affiliation(s)
| | | | - Diana João Matias
- Servicio de Aparato Digestivo, Hospital Universitario de León, León, España
| | | | | | - Luz Monteserín Ron
- Servicio de Aparato Digestivo, Hospital Universitario de León, León, España
| | | | - Santiago Vivas
- Servicio de Aparato Digestivo, Hospital Universitario de León, León, España
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17
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Lee HH, Kim JJ. Benign Disease of the Stomach. J Gastric Cancer 2015; 15:75-6. [PMID: 26161280 PMCID: PMC4496444 DOI: 10.5230/jgc.2015.15.2.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 11/20/2022] Open
Affiliation(s)
- Han Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Jo Kim
- Division of Gastrointestinal Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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18
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Feasibility, safety, and short-term efficacy of the laparoscopic Nissen-Hill hybrid repair. Surg Endosc 2015; 30:551-558. [PMID: 26065538 DOI: 10.1007/s00464-015-4238-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett's esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs. METHODS Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively. RESULTS Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2%) clinical recurrence, and two (4%) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90% with 6% resumption of antisecretory medication. All QOL metrics improved significantly. CONCLUSIONS The hybrid Nissen-Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.
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Abstract
Patients with gastroesophageal reflux disease and Barrett's esophagus can be a management challenge for the treating physician or surgeon. The goals of therapy include relief of reflux symptoms, induction of histologic regression, and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma. Antireflux surgery is effective at achieving these end points, although ongoing follow-up and endoscopic surveillance are essential. In cases of dysplasia or early esophageal neoplasia associated with Barrett's esophagus, endoscopic resection and ablation have supplanted esophagectomy as the standard of care in most cases. Esophageal resection continues to have a role, however, in a minority of appropriately selected candidates.
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Affiliation(s)
- Christian G Peyre
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA
| | - Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
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20
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Bennett C, Moayyedi P, Corley DA, DeCaestecker J, Falck-Ytter Y, Falk G, Vakil N, Sanders S, Vieth M, Inadomi J, Aldulaimi D, Ho KY, Odze R, Meltzer SJ, Quigley E, Gittens S, Watson P, Zaninotto G, Iyer PG, Alexandre L, Ang Y, Callaghan J, Harrison R, Singh R, Bhandari P, Bisschops R, Geramizadeh B, Kaye P, Krishnadath S, Fennerty MB, Manner H, Nason KS, Pech O, Konda V, Ragunath K, Rahman I, Romero Y, Sampliner R, Siersema PD, Tack J, Tham TCK, Trudgill N, Weinberg DS, Wang J, Wang K, Wong JYY, Attwood S, Malfertheiner P, MacDonald D, Barr H, Ferguson MK, Jankowski J. BOB CAT: A Large-Scale Review and Delphi Consensus for Management of Barrett's Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia. Am J Gastroenterol 2015; 110:662-82; quiz 683. [PMID: 25869390 PMCID: PMC4436697 DOI: 10.1038/ajg.2015.55] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/03/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Barrett's esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.
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Affiliation(s)
- Cathy Bennett
- Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | | | | | | | - Yngve Falck-Ytter
- Case Western Reserve University School of Medicine, Case and VA Medical Center Cleveland, Cleveland, Ohio, USA
| | - Gary Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | - John Inadomi
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Khek-Yu Ho
- National University Health System, Singapore, Singapore
| | - Robert Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eamonn Quigley
- Weill Cornell Medical College and Houston Methodist Hospital, Houston, Texas, USA
| | | | | | | | | | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Yeng Ang
- University of Manchester, Manchester, UK
| | - James Callaghan
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | | | - Rajvinder Singh
- Lyell McEwin Hospital/University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - Bita Geramizadeh
- Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Philip Kaye
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sheila Krishnadath
- Gastrointestinal Oncology Research Group, AMC, Amsterdam, The Netherlands
| | | | - Hendrik Manner
- Department of Gastroenterology HSK Wiesbaden, Wiesbaden, Germany
| | - Katie S Nason
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Oliver Pech
- Krankenhaus Barmherzige Brueder, Regensburg, Germany
| | - Vani Konda
- University of Chicago, Chicago, Illinois, USA
| | - Krish Ragunath
- Queens Medical Centre, University of Nottingham, Nottingham, UK
| | | | | | | | | | - Jan Tack
- University of Leuven, Leuven, Belgium
| | | | - Nigel Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | | | - Jean Wang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Jennie Y Y Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - David MacDonald
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Hugh Barr
- Gloucestershire Royal Hospital, Gloucester, UK
| | | | - Janusz Jankowski
- University Hospitals Coventry and Warwickshire and University of Warwick, Coventry, UK
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DeMeester SR. Barrett's oesophagus: treatment with surgery. Best Pract Res Clin Gastroenterol 2015; 29:211-7. [PMID: 25743467 DOI: 10.1016/j.bpg.2014.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/08/2014] [Accepted: 12/11/2014] [Indexed: 01/31/2023]
Abstract
Barrett's oesophagus develops as a consequence of gastro-oesophageal reflux disease and may progress to oesophageal adenocarcinoma. Antireflux surgery is an option for patients with reflux disease, but the efficacy and impact on the natural history of disease in patients with Barrett's oesophagus is controversial. This review addresses the existing data on these important issues.
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de Jonge PJF, Spaander MC, Bruno MJ, Kuipers EJ. Acid suppression and surgical therapy for Barrett's oesophagus. Best Pract Res Clin Gastroenterol 2015; 29:139-50. [PMID: 25743462 DOI: 10.1016/j.bpg.2014.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 10/12/2014] [Accepted: 11/02/2014] [Indexed: 02/09/2023]
Abstract
Gastro-oesophageal reflux disease is a common medical problem in developed countries, and is a risk factor for the development of Barrett's oesophagus and oesophageal adenocarcinoma. Both proton pump inhibitor therapy and antireflux surgery are effective at controlling endoscopic signs and symptoms of gastro-oesophageal reflux in patients with Barrett's oesophagus, but often fail to eliminate pathological oesophageal acid exposure. The current available studies strongly suggest that acid suppressive therapy, both pharmacological as well as surgical acid suppression, can reduce the risk the development and progression in patients with Barrett's oesophagus, but are not capable of complete prevention. No significant differences have been found between pharmacological and surgical therapy. For clinical practice, patients should be prescribed a proton pump inhibitor once daily as maintenance therapy, with the dose guided by symptoms. Antireflux surgery can be a good alternative to proton pump inhibitor therapy, but should be primarily offered to patients with symptomatic reflux, and not to asymptomatic patients with the rationale to protect against cancer.
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Affiliation(s)
- Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, The Netherlands.
| | - Manon C Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, The Netherlands
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23
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Almond LM, Old O, Barr H. Strategies for the prevention of oesophageal adenocarcinoma. Int J Surg 2014; 12:931-5. [PMID: 25091397 DOI: 10.1016/j.ijsu.2014.07.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/29/2014] [Indexed: 01/30/2023]
Abstract
The incidence of oesophageal adenocarcinoma has increased by 500% over the past 30 years [1]. Improved understanding of the mechanisms of neoplastic progression provides an opportunity to reverse this trend. A thorough review of emerging strategies aiming to prevent the formation of oesophageal malignancy is presented. These include dietary modification, chemoprevention, early endoscopic identification and treatment of premalignant disease, and the potential for a non-endoscopic screening test. Oesophageal adenocarcinoma has become a major public health problem in the West and it is essential that clinicians are fully informed of risk reduction strategies so that they can be actively promoted in the community.
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Affiliation(s)
| | - Oliver Old
- Biophotonics Research Unit, Gloucester, UK
| | - Hugh Barr
- Department of Oesophagogastric Surgery, Gloucestershire Hospitals NHS Trust, UK
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24
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The impact of laparoscopic anti-reflux surgery in patients with Barrett's esophagus. Surg Endosc 2014; 28:3279-84. [PMID: 24935200 DOI: 10.1007/s00464-014-3601-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 05/03/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Barrett's esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD. METHODS We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE. RESULTS Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1-16 years) after surgery. Regression of BE occurred in 18 (22%) patients while in 6 (7%) BE progressed to dysplasia or cancer. Thirty-six (43%) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41%) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82%) of 82 patients completed the post-operative questionnaire; 86% of these patients reported improvement in heartburn and regurgitation. CONCLUSIONS LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22% of patients and progression in 7%. Thus, continued surveillance of Barrett's is needed after LARS.
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Radiologic and endoscopic characteristics of laparoscopic antireflux wrap: correlation with outcome. Int Surg 2014; 97:189-97. [PMID: 23113845 DOI: 10.9738/cc120.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe's classification of the postoperative valve was used for the definition of a "normal" or "defective" wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A "normal" antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). "Defective" antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.
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Two-year subjective, objective, quality of life, and endoscopic follow-up after laparoscopic Nissen-Rossetti in patients with columnar-lined esophagus. Surg Laparosc Endosc Percutan Tech 2014; 23:292-8. [PMID: 23751995 DOI: 10.1097/sle.0b013e31828b8758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Barrett esophagus (BE) is a complication of gastroesophageal reflux disease. We wish to determine the effects of surgery on the histology of the esophageal mucosa and evaluate Quality of Life. MATERIALS AND METHODS Twenty-seven patients with columnar-lined esophagus (CLE) metaplasia underwent laparoscopic Nissen-Rossetti fundoplication. Patients were submitted to close follow-up. RESULTS One patient voluntarily left follow-up after surgery. CLE was still present in 18 patients (66.6%); no patient developed dysplasia or esophageal adenocarcinoma. Two patients with gastric metaplasia and 1 patient with intestinal metaplasia had regression at 12 and 24 months after surgery (11.1%). DeMeester and Johnson score decreased from 38.69 (SD ± 51.44) to 11.99 (SD ± 18.08) at 6 months, 12.69 (SD ± 12.91) at 12 months, and it was 11.38 (SD ± 6.43) at 24 months. Preoperative gastroesophageal reflux disease-health related quality of life was 19.90 (SD ± 18.54), 9.80 (SD ± 8.77) at 6 months, 9.57 (SD ± 9.14) at 12 months, and 11.53 (SD ± 6.48) at 24 months. Short form-36 measurement showed significant improvement. CONCLUSIONS Management of CLE requires multidisciplinary approach. Medical therapy does not prevent biliary reflux into the esophagus. Surgical therapy is effective and long lasting. It should be performed by experienced surgical teams.
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Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang JY, Watson P, Trudgill N, Patel P, Kaye PV, Sanders S, O'Donovan M, Bird-Lieberman E, Bhandari P, Jankowski JA, Attwood S, Parsons SL, Loft D, Lagergren J, Moayyedi P, Lyratzopoulos G, de Caestecker J. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut 2014; 63:7-42. [PMID: 24165758 DOI: 10.1136/gutjnl-2013-305372] [Citation(s) in RCA: 814] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.
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Huerta-Iga F, Tamayo-de la Cuesta JL, Noble-Lugo A, Hernández-Guerrero A, Torres-Villalobos G, Ramos-de la Medina A, Pantoja-Millán JP. [The Mexican consensus on gastroesophageal reflux disease. Part II]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:231-9. [PMID: 24290724 DOI: 10.1016/j.rgmx.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/14/2013] [Accepted: 05/27/2013] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002. METHODS Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher. RESULTS Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%. CONCLUSION Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.
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Affiliation(s)
- F Huerta-Iga
- Encargado del Servicio de Endoscopia, Hospital Ángeles Torreón, Coahuila, México.
| | | | - A Noble-Lugo
- Departamento de Enseñanza, Hospital Español de México, México D.F., México
| | - A Hernández-Guerrero
- Jefe del Servicio de Endoscopia, Instituto Nacional de Cancerología, México D.F., México
| | - G Torres-Villalobos
- Servicio de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México D.F., México
| | | | - J P Pantoja-Millán
- Cirugía del Aparato Digestivo, Hospital Ángeles del Pedregal, México D.F., México
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Huerta-Iga F, Tamayo-de la Cuesta J, Noble-Lugo A, Hernández-Guerrero A, Torres-Villalobos G, Ramos-de la Medina A, Pantoja-Millán J. The Mexican consensus on gastroesophageal reflux disease. Part II. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2013. [DOI: 10.1016/j.rgmxen.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Kim JJ. Upper gastrointestinal cancer and reflux disease. J Gastric Cancer 2013; 13:79-85. [PMID: 23844321 PMCID: PMC3705136 DOI: 10.5230/jgc.2013.13.2.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 06/07/2013] [Accepted: 06/07/2013] [Indexed: 12/17/2022] Open
Abstract
There is a growing evidence that gastroesophageal reflux disease is related to several upper gastrointestinal cancers, mainly the esophageal adenocarcinoma and a certain type of gastric cardia adenocarcinoma. Currently, the incidence of gastroesophageal reflux disease is rapidly increasing in Korea. Therefore, there is a possibility of such increasing cancerous incidents, similar to the western worlds. In this article, the relationship between gastroesophageal reflux disease and several upper gastrointestinal cancers, the components of refluxate which has possible causal relationship with carcinogenesis, and the clinical implications of such relationship in the management of gastroesophageal reflux disease patients are discussed through the review of literature.
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Affiliation(s)
- Jin-Jo Kim
- Division of Gastrointestinal Surgery, Department of Surgery, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
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31
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Billeter AT, Barnett RE, Druen D, Polk HC, van Berkel VH. MicroRNA as a new factor in lung and esophageal cancer. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200070 DOI: 10.1053/j.semtcvs.2012.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lung cancer is the most lethal cancer due to late detection in advanced stages; early diagnosis of lung cancer allows surgical treatment and improves the outcome. The prevalence of gastroesophageal reflux-related adenocarcinomas of the esophagus is increasing; repetitive surveillance endoscopies are necessary to detect development of cancer. A blood-based biomarker would simplify the diagnosis and treatment of both diseases. MicroRNAs (miRNAs) are short RNA strands that interfere with protein production. miRNAs play pivotal roles in cell homeostasis, and dysregulation of miRNAs can lead to the development of cancer. miRNAs can be found in all body fluids and have been proposed to serve as messengers between closely localized cells but also distant organs. Cancer cells actively secrete miRNAs, and these miRNA profiles can be found in blood. We outline, here, how these miRNAs may aid in diagnosis and treatment of lung and esophageal cancers, as well as their apparent limitations.
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Affiliation(s)
- Adrian T Billeter
- Department of Surgery, Price Institute of Surgical Research, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA.
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Lee SB, Jeon KM, Kim BS, Kim KC, Jung HY, Choi YB. Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:330-7. [PMID: 23741690 PMCID: PMC3671001 DOI: 10.4174/jkss.2013.84.6.330] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 03/19/2013] [Accepted: 04/05/2013] [Indexed: 12/23/2022]
Abstract
Purpose There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. Methods Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360° wrapping was performed on all patients. Results Eleven male and four female patients were evaluated and treated with an average age of 58.1 ± 14.1 years. The average surgical time was 118.9 ± 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. Conclusion The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.
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Affiliation(s)
- Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Miyazaki T, Inose T, Tanaka N, Yokobori T, Suzuki S, Ozawa D, Sohda M, Nakajima M, Fukuchi M, Kato H, Kuwano H. Management of Barrett's esophageal carcinoma. Surg Today 2013; 43:353-60. [PMID: 23283352 DOI: 10.1007/s00595-012-0468-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 05/13/2012] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is the premalignant lesion from which esophageal adenocarcinoma near the esophagogastric junction arises. The management of BE and the treatment of Barrett's esophageal adenocarcinoma (BEA) are important clinical issues in Europe and the United States. As the Helicobacter pylori infection rate in Japan is decreasing in the younger population, the incidence of BE and adenocarcinoma arising from BE may start increasing. Thus, we review the current status of BEA and its management. Magnifying endoscopy with narrow-band imaging is important for diagnosing dysplasia arising from BE. In Japan, adenocarcinoma arising from BE is managed the same way as squamous cell carcinoma in the same location. Strategies to prevent BEA may include medication such as non-steroidal anti-inflammatory drugs and proton pump inhibitors, and anti-reflux surgery. Understanding the pathophysiology of BE will help to reduce the incidence of BEA.
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Affiliation(s)
- Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.
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Chisholm JA, Mayne GC, Hussey DJ, Watson DI. Molecular biomarkers and ablative therapies for Barrett's esophagus. Expert Rev Gastroenterol Hepatol 2012; 6:567-81. [PMID: 23061708 DOI: 10.1586/egh.12.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Barrett's esophagus is the major risk factor for esophageal adenocarcinoma. Endoscopic interventions that ablate Barrett's esophagus mucosa lead to replacement with a new squamous (neosquamous) mucosa, but it can be difficult to achieve complete ablation. Knowing whether cancer is less likely to develop in neosquamous mucosa or residual Barrett's esophagus after ablation is critical for determining the efficacy of treatment. This issue can be informed by assessing biomarkers that are associated with an increased risk of progression to adenocarcinoma. Although there are few postablation biomarker studies, evidence suggests that neosquamous mucosa may have a reduced risk of adenocarcinoma in patients who have been treated for dysplasia or cancer, but some patients who do not have complete eradication of nondysplastic Barrett's esophagus may still be at risk. Biomarkers could be used to optimize endoscopic surveillance strategies following ablation, but this needs to be assessed by clinical studies and economic modeling.
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Affiliation(s)
- Jacob A Chisholm
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia
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Pensabene L, Cohen MC, Thomson M. Clinical implications of molecular changes in pediatric Barrett's esophagus. Curr Gastroenterol Rep 2012; 14:253-61. [PMID: 22373715 DOI: 10.1007/s11894-012-0252-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett's esophagus (BE) is a preneoplastic condition that predisposes to esophageal adenocarcinoma. Although data on the occurrence of BE in children are limited, recent studies have suggested an increase in the pediatric population. BE is thought to be a complex disease in which individual genetic predisposition interacts with environmental stimuli. Early premalignant clones produce biological and genetic heterogeneity, resulting in stepwise changes in differentiation, proliferation, and apoptosis, allowing disease progression under selective pressure. The value of endoscopic surveillance biopsy for dysplasia and carcinoma in patients with BE is controversial. Thus, the recognition of early and objective alternative risk markers, less susceptible of sampling error, will be of relevance in the management of BE patients. The possibility of performing molecular genetics on paraffin-embedded biopsies will expand our understanding of the natural history of BE and may lead to the use of biomarkers to inform treatment strategies.
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Affiliation(s)
- Licia Pensabene
- Department of Paediatrics, Pugliese-Ciaccio Hospital, University "Magna Græcia" of Catanzaro, Catanzaro, Italy,
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Kastelein F, Spaander MCW, Biermann K, Vucelic B, Kuipers EJ, Bruno MJ. Role of acid suppression in the development and progression of dysplasia in patients with Barrett's esophagus. Dig Dis 2011; 29:499-506. [PMID: 22095018 DOI: 10.1159/000331513] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Barrett's esophagus (BE) usually develops in patients with gastroesophageal reflux disease and therefore it has been suggested that esophageal acid exposure plays an import role in the initiation of BE and its progression towards esophageal adenocarcinoma (EAC). The mechanisms whereby acid exposure causes BE are not completely revealed and the potential role of esophageal acid exposure in carcinogenesis is unclear as well. Since acid exposure is thought to play an important role in the progression of BE, therapies aimed at preventing the development of EAC have primarily focused on pharmacological and surgical acid suppression. In clinical practice, acid suppression is effective in relieving reflux symptoms and decreases esophageal acid exposure in most patients. However, in some individuals, pathological acid exposure persists and these patients continue to be at risk for developing dysplasia or EAC. To date, published trials suggest that acid suppression is able to prevent the development and progression of dysplasia in patients with BE, but definite and compelling proof is still lacking. This article reviews the mechanisms of acid-induced carcinogenesis in BE and the role of acid suppression in the prevention of neoplastic progression.
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Affiliation(s)
- F Kastelein
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Appelman HD, Umar A, Orlando RC, Sontag SJ, Nandurkar S, El-Zimaity H, Lanas A, Parise P, Lambert R, Shields HM. Barrett's esophagus: natural history. Ann N Y Acad Sci 2011; 1232:292-308. [DOI: 10.1111/j.1749-6632.2011.06057.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Shields HM, Nardone G, Zhao J, Wang W, Xing Z, Fang D, Jacobson BC, Romero Y, Dvorak K, Goldman A, Pellegrini CA, Wiley EL, Peura DA, Tatum RP, Schnell TG. Barrett's esophagus: prevalence and incidence of adenocarcinomas. Ann N Y Acad Sci 2011; 1232:230-47. [DOI: 10.1111/j.1749-6632.2011.06054.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Khazzaka A, Sarkis R. Fundoplication combined with mediogastric plication. Surg Obes Relat Dis 2011; 9:398-403. [PMID: 21978753 DOI: 10.1016/j.soard.2011.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 07/28/2011] [Accepted: 08/29/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this pilot study was to demonstrate the feasibility and procedural safety of laparoscopic fundoplication combined with mediogastric plication in patients with a body mass index of 32-35 kg/m(2). METHODS Sixteen patients underwent laparoscopic fundoplication combined with mediogastric plication. All procedures were performed with the patient under general anesthesia. The 1-year follow-up results encompassed gastroesophageal reflux disease recovery and excess weight loss. RESULTS The procedure time varied from 65 to 95 minutes. No serious procedure-related complications occurred. Gastroesophageal reflux disease-related symptoms resolved in all patients (P = .000). The excess weight loss was 10 ± 4 kg (58%) 1 year after the procedure. The 1-year follow-up excess weight was significantly less than the baseline excess weight (P = .000). The average body mass index decreased from 33.8 ± 1.9 kg/m(2) at baseline to 27.2 ± 1.7 kg/m(2) at 1 year (P = .02). Of the 16 patients, 14 had an excess weight loss of 62%, and 2 sweet-eaters had an excess weight loss of 33%. At 1 year of follow-up, the excess weight in those who smoked (n = 10) was greater than that of nonsmokers (n = 6; P = .02). However, smoking did not seem to significantly affect excess weight loss (P = .065). CONCLUSION Fundoplication combined with mediogastric plication produced a total recovery from gastroesophageal reflux disease and an excess weight loss of 62% in 87.5% of patients after 1 year of follow-up. This procedure is technically feasible, and no serious procedure-related complications occurred. The follow-up is ongoing to investigate the efficacy and long-term durability of the procedure.
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Affiliation(s)
- Aline Khazzaka
- Surgical Research Laboratory, Saint Joseph University Medical School, Beirut, Lebanon.
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Fujimura T, Oyama K, Sasaki S, Nishijima K, Miyashita T, Ohta T, Koichi M, Takanori H. Inflammation-related carcinogenesis and prevention in esophageal adenocarcinoma using rat duodenoesophageal reflux models. Cancers (Basel) 2011; 3:3206-24. [PMID: 24212953 PMCID: PMC3759194 DOI: 10.3390/cancers3033206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 08/02/2011] [Accepted: 08/04/2011] [Indexed: 12/30/2022] Open
Abstract
Development from chronic inflammation to Barrett's adenocarcinoma is known as one of the inflammation-related carcinogenesis routes. Gastroesophageal reflux disease induces regurgitant esophagitis, and esophageal mucosa is usually regenerated by squamous epithelium, but sometimes and somewhere replaced with metaplastic columnar epithelium. Specialized columnar epithelium, so-called Barrett's epithelium (BE), is a risk factor for dysplasia and adenocarcinoma in esophagus. Several experiments using rodent model inducing duodenogastroesophageal reflux or duodenoesophageal reflux revealed that columnar epithelium, first emerging at the proliferative zone, progresses to dysplasia and finally adenocarcinoma, and exogenous carcinogen is not necessary for cancer development. It is demonstrated that duodenal juice rather than gastric juice is essential to develop esophageal adenocarcinoma in not only rodent experiments, but also clinical studies. Antireflux surgery and chemoprevention by proton pump inhibitors, nonsteroidal anti-inflammatory drugs, selective cyclooxygenase-2 inhibitors, green tea, retinoic acid and thioproline showed preventive effects on the development of Barrett's adenocarcinoma in rodent models, but it remains controversial whether antireflux surgery could regress BE and prevent esophageal cancer in clinical observation. The Chemoprevention for Barrett's Esophagus Trial (CBET), a phase IIb, multicenter, randomized, double-masked study using celecoxib in patients with Barrett's dysplasia failed to prove to prevent progression of dysplasia to cancer. The AspECT (Aspirin Esomeprazole Chemoprevention Trial), a large multicenter phase III randomized trial to evaluate the effects of esomeprazole and/or aspirin on the rate of progression to high-grade dysplasia or adenocarcinoma in patients with BE is now ongoing.
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Affiliation(s)
- Takashi Fujimura
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +81-76-265-2362; Fax: +81-76-234-4260
| | - Katsunobu Oyama
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Shozo Sasaki
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Koji Nishijima
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Tomoharu Miyashita
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Tetsuo Ohta
- Gastroenterologic Surgery, Kanazawa University Hospital, Kanazawa, Japan, 13-1 Takaramachi, Kanazawa, Ishikawa 920-8641, Japan; E-Mails: (K.O.); (S.S.); (K.N.); (T.M.); (T.O.)
| | - Miwa Koichi
- Houju Memorial Hospital, Nomi, Japan, 11-71 Midorigaoka, Nomi, Ishikawa 923-1226, Japan; E-Mail:
| | - Hattori Takanori
- Division of Molecular and Diagnostic Pathology, Shiga University of Medical Science, Otsu, Japan, Seta Tsukinowa-cho, Otsu, Shiga 520-2192, Japan; E-Mail:
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Kauttu TME, Rantanen TK, Sihvo EI, Räsänen JV, Puolakkainen P, Salo JA. Esophageal adenocarcinoma arising after antireflux surgery: a population-based analysis. Eur J Cardiothorac Surg 2011; 40:1450-4; discussion 1454. [PMID: 21546258 DOI: 10.1016/j.ejcts.2011.02.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Fundoplication is widely used to treat gastroesophageal reflux disease (GERD). Whether it diminishes the development of esophageal adenocarcinoma (EAC) is, however, controversial. Our aim was to define, at the national level in Finland, frequency and predisposing factors for post-fundoplication EAC. METHODS For this population-based study from 1980 to 2006, Finland's administrative databases provided preliminary data. Analyses of EAC patient records (N = 1035) led us to include those with preceding antireflux surgery. Conservatively treated patients were not analyzed. The EAC incidence in patients with antireflux surgery was compared with that in the general population (1987-2006) by means of standardized incidence ratio (SIR). RESULTS A total of 53 (5.1%) EAC patients had undergone antireflux surgery. Of these patients with male predominance (74%), preoperatively 41 (77%) had developed endoscopic esophagitis, 40 (75%) hiatal hernia, 24 (45%) Barrett's esophagus (BE), nine (17%) ulcer in the esophagus or gastroesophageal junction, and three (6%) stricture. Postoperatively, histologically confirmed BE was present in 42 (79%). Antireflux surgery had preceded EAC at a mean interval of 10.1 years (range 0.5-25.6 years). This interval was significantly (p=0.02) shorter in patients with long-term functioning fundoplication (n = 15; 30%) at EAC diagnosis (6.4 years, range 0.5-15.2 years) than in those (n = 22, 44%) with failure (11.2 years, range 4.0-24.3 years). Overall, the SIR for EAC after antireflux surgery (1987-2006) was 9.21. CONCLUSIONS Intention-to-treat GERD with antireflux surgery does not prevent EAC. It often develops more than 5 years postoperatively, also in the patients with a good antireflux barrier. Only one-third of the patients had, however, a functioning fundoplication. Preoperative BE and endoscopic esophagitis may be risk factors. Prospective, long-term, randomized studies in experienced centers may reveal the definite effect of antireflux surgery on EAC development.
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Affiliation(s)
- Tuuli M E Kauttu
- Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Haiart S, Watson DI, Leong MP, Astill D, Bright T, Hussey DJ. MicroRNA-196a & microRNA-101 expression in Barrett's oesophagus in patients with medically and surgically treated gastro-oesophageal reflux. BMC Res Notes 2011; 4:41. [PMID: 21352563 PMCID: PMC3055819 DOI: 10.1186/1756-0500-4-41] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 02/27/2011] [Indexed: 12/15/2022] Open
Abstract
Background Proton pump inhibitor (PPI) medication and surgical fundoplication are used for the control of gastro-oesophageal reflux in patients with Barrett's oesophagus, but differ in their effectiveness for both acid and bile reflux. This might impact on the inflammatory processes that are associated with progression of Barrett's oesophagus to cancer, and this may be evident in the gene expression profile and microRNA expression pattern in Barrett's oesophagus mucosa. We hypothesised that two miRNAs with inflammatory and oncogenic roles, miR-101 and miR-196a, are differentially expressed in Barrett's oesophagus epithelium in patients with reflux treated medically vs. surgically. Findings Mucosal tissue was obtained at endoscopy from patients with Barrett's oesophagus whose reflux was controlled by proton pump inhibitor (PPI) therapy (n = 20) or by fundoplication (n = 19). RNA was extracted and the expression of miR-101 and miR-196a was measured using real-time reverse transcription - polymerase chain reaction. There were no significant differences in miR-101 and miR-196a expression in Barrett's oesophagus epithelium in patients treated by PPI vs. fundoplication (p = 0.768 and 0.211 respectively). Secondary analysis showed a correlation between miR-196a expression and Barrett's oesophagus segment length (p = 0.014). Conclusion The method of reflux treatment did not influence the expression of miR-101 and miR-196a in Barrett's oesophagus. This data does not provide support to the hypothesis that surgical treatment of reflux better prevents cancer development in Barrett's oesophagus. The association between miR-196a expression and Barrett's oesophagus length is consistent with a tumour promoting role for miR-196a in Barrett's oesophagus.
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Affiliation(s)
- Sebastien Haiart
- Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, South Australia 5042, Australia.
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Abstract
Barrett's esophagus (BE) is defined as a metaplastic change of the distal esophageal epithelium from squamous to columnar type epithelium with the presence of intestinal metaplasia. There is a striking geographic variation in the prevalence rates of BE. Most epidemiological data on BE are derived from patients undergoing endoscopy and do not reflect prevalence rates in the general population. BE is much more common in the West when compared with Asia and Africa. Although BE is less common in Asia, the demographics are similar to the West, being predominantly found in older men with longer duration of reflux symptoms. Some studies from the West have suggested an increase in prevalence rates of BE. An increase in prevalence rates will have significant implications for health resource utilization and costs, due to the small but significant risk of developing esophageal adenocarcinoma. Endoscopic surveillance with the aim of detecting early lesions has been advocated. Compared with conventional white-light endoscopy with blind four-quadrant biopsies, the use of image-enhanced endoscopy, including chromoendoscopy, may improve detection of subtle mucosal irregularities and facilitate targeted biopsies. However, a truly cost-effective surveillance strategy remains to be determined.
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Affiliation(s)
- Kwong Ming Fock
- Department of Gastroenterology, Changi General Hospital, 2 Simei Street 3, 529889 Singapore.
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Mohamed AA, Mahran KM, Zaazou MM. Impact of laparoscopic Nissen fundoplication on non-complicated Barrett's esophagus. Saudi J Gastroenterol 2011; 17:185-8. [PMID: PMC3122088 PMCID: PMC3122088 DOI: 10.4103/1319-3767.80381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/AIM Laparoscopic fundoplication can alter the natural course of Barrett's esophagus (BE). This study was undertaken to assess this role in patients with non-complicated BE. MATERIALS AND METHODS From October 2004 to October 2009, 43 patients with BE (32 men and 11 women) underwent laparoscopic Nissen fundoplication surgery in the Department of Surgery at Minia University Hospital. The median age of these patients was 46 years (range: 22-68 years). Patients with high-grade dysplasia, invasive cancer, or previous antireflux surgery were excluded. All 43 patients had gastroesophageal reflux symptoms. Heartburn was present in all patients, regurgitation in 41 (95.3%), dysphagia in 8 (18.6%), retrosternal pain in 30 (69.8%), upper gastrointestinal hemorrhage in 6 (13.9%), and respiratory symptoms in 19 (44.2%). Nissen fundoplication was performed in all patients. Thirty-four patients (79.1%) had concomitant hiatal hernia and nine patients (20.9%) had low-grade dysplasia. RESULTS The median follow-up period was 25.6 months. There was significant improvement of symptoms after surgery (P<0.05). Eight (18.6%) of those with short-segment BE had total regression and four (9.3%) of those with long-segment BE had a decrease in total length. Among the nine patients with preoperative low-grade dysplasia, dysplasia disappeared in seven, remained unchanged in one, and progressed to in situ adenocarcinoma in one patient. CONCLUSIONS laparoscopic fundoplication succeeded in controlling symptoms but had unpredictable effect on dysplasia and regression of BE. Laparoscopic fundoplication does not eliminate the risk of developing esophageal adenocarcinoma and therefore, endoscopic follow-up should be continued in these patients.
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Affiliation(s)
| | - Khaled M. Mahran
- Minia University Hospital, Minia, Egypt,Address for correspondence: Dr. Khaled Mohamed Mahran, 66 Adnan El Malky Street, 61111, Minia, Egypt. E-mail:
| | - Mohamed M. Zaazou
- Misr University for Science and Technology (MUST) Hospital, 6th of October City, Egypt
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Lundell L. Surgical therapy of gastro-oesophageal reflux disease. Best Pract Res Clin Gastroenterol 2010; 24:947-59. [PMID: 21126706 DOI: 10.1016/j.bpg.2010.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 09/21/2010] [Accepted: 09/23/2010] [Indexed: 01/31/2023]
Abstract
Surgery should always be looked upon as complementary to medical therapy in the long-term management of patients with chronic GORD. Available medical therapies are effective and adequate for the control of disease manifestations in the great majority of GORD patients. For patients who have a suboptimal disease control under medical therapy and in those who for various reasons want to discuss an alternative to medical long-term therapy, the following message can be transmitted. Anti reflux surgery is a well-documented effective long-term therapeutic alternative to control GORD. The outcome after surgery is dependent on the experience and quality of the surgeon. These operations are safe but mortality can never attain a zero level and the morbidity has to be realised. Anti reflux surgery has to be centralised within each country. With the aim of optimising the outcome of anti reflux surgery, the surgeon has to perform and master a delicate act of balance on the choice between various fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated somewhat more frequent mechanical side-effects. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without compromising the level of reflux control and can therefore often be recommended. Most studies present very promising results following anterior partial fundoplications. The spectrum of postfundoplication symptoms can be minimised provided that the surgeon fully comprehend the mechanism of action of these procedures and adhere to technical perfectionism. Evaluation and management of failures after anti reflux surgery have to be centralised within each country.
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Affiliation(s)
- Lars Lundell
- Department of Surgery, Gastrocentrum, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Esophageal adenocarcinoma after Nissen's fundoplication for Barrett's esophagus: report of a case. Surg Today 2010; 40:1173-5. [PMID: 21110164 DOI: 10.1007/s00595-009-4221-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 07/23/2009] [Indexed: 10/18/2022]
Abstract
It remains unclear whether surgical treatment of gastro-esophageal reflux disease (GERD) and Barrett's esophagus (BE) decreases the long-term risk of lower esophagus malignancy; yet, proposed reductions in Barrett's epithelial transformation have been used as a rationale for antireflux surgery. We report the case of a 63-year-old woman with a 40-year history of GERD, whose symptoms returned after a Nissen fundoplication. A gastroscopy done 3 years later revealed BE. Despite close surveillance, adenocarcinoma of the lower esophagus was diagnosed 8 years after the original surgery. Thus far, there is insufficient evidence to convince practitioners that surgery should be the first line of treatment to prevent malignant change in BE. Further well-standardized, prospective trials are required. Our case demonstrates that antireflux surgery in a patient with GERD and BE cannot be relied upon to prevent adenocarcinoma.
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Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Zehetner J, DeMeester SR, Ayazi S, Costales JL, Augustin F, Oezcelik A, Lipham JC, Sohn HJ, Hagen JA, DeMeester TR. Long-term follow-up after anti-reflux surgery in patients with Barrett's esophagus. J Gastrointest Surg 2010; 14:1483-91. [PMID: 20824377 DOI: 10.1007/s11605-010-1322-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Factors associated with the risk of progression of Barrett's esophagus remain unclear, and the impact of therapy on this risk remains uncertain. The aim of this study was to assess patients followed long-term after anti-reflux surgery for Barrett's esophagus. METHODS A retrospective review was performed of all patients with Barrett's who underwent anti-reflux surgery from 1989 to 2009 and had ≥5 years of follow-up. RESULTS There were 303 patients and 75 had follow-up ≥5 years. Median follow-up time for the 75 patients was 8.9 years (range 5-18). Regression was seen in 31%. Progression occurred in 8%, and these patients were significantly more likely to have a failed fundoplication (67% vs. 16%, p = 0.0129). The rate of progression from non-dysplastic Barrett's to high-grade dysplasia or cancer was 0.8% per patient year, and was seven times higher in patients with a failed fundoplication. CONCLUSION Compared to the accepted rate of progression of non-dysplastic Barrett's to high-grade dysplasia or cancer of 1.0% per patient year, anti-reflux surgery reduces this rate during long-term follow-up. The rate of progression was significantly lower in patients with an intact compared to a disrupted fundoplication, further suggesting that anti-reflux surgery can alter the natural history of Barrett's esophagus.
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Affiliation(s)
- Joerg Zehetner
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Van Den Eynde M, Jouret-Mourin A, Sempoux C, Piessevaux H, Deprez PH. Endoscopic mucosal or submucosal resection of early neoplasia in Barrett's esophagus after antireflux surgery. Gastrointest Endosc 2010; 72:855-61. [PMID: 20883865 DOI: 10.1016/j.gie.2010.06.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 06/03/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic resection and radiofrequency ablation are now established therapies for high-grade intraepithelial neoplasia and mucosal cancer complicating Barrett's esophagus. These techniques may be more challenging in patients with previous antireflux surgery, because of poor visibility and accessibility. OBJECTIVE To assess the results of endoscopic resection for early neoplasia complicating Barrett's esophagus after antireflux surgery. DESIGN Case series, retrospective review. SETTING Single tertiary-care referral center. PATIENTS This study involved 7 patients treated for Barrett's neoplasia by endoscopic resection between 2001 and 2009. INTERVENTIONS Endoscopic resection was performed by using the EMR cap technique or by endoscopic submucosal dissection. MAIN OUTCOME MEASUREMENTS The curative resection rate, complications, follow-up, and complete remission status were determined. RESULTS Seven patients underwent endoscopic resection (mean number of sessions, 3.1; range, 1-6): endoscopic submucosal dissection in 3 patients and EMR in 4 patients. Two patients needed additional argon plasma coagulation. Pathology examination disclosed invasive adenocarcinoma in 3 patients and high-grade intraepithelial neoplasia in 4 patients. At the last follow-up examination, all patients were in complete remission. Major procedure-related complications were not encountered. LIMITATIONS Small number of patients, single center, retrospective study. CONCLUSIONS We demonstrated that full endoscopic resection by using EMR or endoscopic submucosal dissection in patients with previous antireflux surgery can be achieved successfully and safely. These patients can be treated endoscopically, similarly to patients without previous surgery.
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Affiliation(s)
- Marc Van Den Eynde
- Gastroenterology Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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50
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Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010; 24:2647-69. [PMID: 20725747 DOI: 10.1007/s00464-010-1267-8] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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