Barrett's esophagus without esophageal stricture does not increase the rate of failure of Nissen fundoplication

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Barrett's esophagus: A historical perspective, an update on core practicalities and predictions on future evolutions of management

Interpretation of exploding knowledge about Barrett's esophagus is impaired by use of several conflicting definitions. Because any histological type of esophageal columnar metaplasia carries risk for esophageal adenocarcinoma, the diagnosis of Barrett's esophagus should no longer require demonstration of intestinal-type metaplasia. Endoscopic recognition and grading of Barrett's esophagus remains a significant source of ambiguity. Reflux disease is a key factor for development of Barrett's esophagus, but other factors must underlie its development, since it occurs in only a minority of reflux disease patients. Neither antireflux surgery nor proton pump inhibitor (PPI) therapy has major impacts on cancer risk. Within a year, a major trial should indicate whether low-dose aspirin usefully reduces cancer risk. The best referral centers have transformed the accuracy of screening and surveillance for early curable esophageal adenocarcinoma by use of enhanced and novel endoscopic imaging, visually-guided, rather than blind biopsies and by partnership with expert pathologists. General endoscopists now need to upgrade their skills and equipment so that they can rely mainly on visual targeting of biopsies on mucosal areas of concern in their surveillance practice. General pathologists need to greatly improve their interpretation of biopsies. Endoscopic therapy now achieves very high rates of cure of high-grade dysplasia and esophageal adenocarcinoma with minimal morbidity and risk. Such results will only be achieved by skilled interventional endoscopists. Esophagectomy should now be mainly restricted to patients whose cancer has extended into and beyond the submucosa. Weighing risks and benefits in the management of Barrett's esophagus is difficult, as is the process of adequately informing patients about their specific cancer risk.

Surgical therapy of gastro-oesophageal reflux disease

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.

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

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

Technical Controversies in Fundoplication Surgery

Gastroesophageal reflux disease (GERD) is a common health problem affecting more than 50% of the population. For those who experience more than occasional symptoms, GERD has a profound effect on their quality of life. With the advent of laparoscopic surgery, fundoplication has been used to treat GERD. Fundoplication also is used in the surgical management of paraesophageal hernias. Technical controversies are addressed in this article, including open versus laparoscopic approaches, the choice of complete (360 degres) or partial fundoplication, whether or not a gastroplasty is required, and the use of prosthetic materials in crural repair.

Does laparoscopic Nissen fundoplication prevent the progression of Barrett's oesophagus? Is the length of Barrett's a factor?

Introduction:

Recent studies have suggested that both laparoscopic and open anti-reflux surgery may produce regression of Barrett’s mucosa.

Material and methods;

We reviewed 21 patients (13M: 8F, mean age 46.7±3.18 years) with documented Gastroesophageal Reflux Disease (GERD) and Non-dysplastic Barrett’s esophagus (15 patients ?3 cm segment, 6 patients < 3 cm segment) on long term proton pump inhibitor therapy who underwent laparoscopic Nissen fundoplication (LNF) between 1993 and 2000. All patients had undergone pre and yearly postoperative upper GI endoscopy with 4 quadrant biopsies every 2 cm. All patients also underwent pre- and 6 months postoperative 24-hr pH study, esophageal manometry, SF36, and GERD symptom score. The mean duration of GERD symptoms was 8.4±1.54 years pre-operative. The mean follow-up after surgery was 39±6.32 months.

Results:

Postoperatively, there was significant improvement in reflux symptom score (37.5 ± 3.98 points versus 8.7 ± 2.46 points, P = 0.0001), % acid reflux in 24 hr (26.5 ± 3.91% versus 2.1 ± 0.84%, P< 0.0001) and an increase in lower esophageal sphincter pressure (3.71 ± 1.08 mmHg versus 12.29 ± 1.34 mmHg, P = 0.0053). Complete or partial regression of Barrett’s mucosa occurred in 9 patients. All patients with complete regression had <4 cm segment of Barrett’s. Progression or cancer transformation was not observed in any of the patients.

Conclusion:

LNF in patients with Barrett’s oesophagus results in significant control of GERD symptoms. LNF can prevent progression of Barrett’s oesophagus and in patients with Barrett’s <4 cm may lead to complete regression.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during follow-up to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett's esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.