Long-Term Follow-Up After Anti-Reflux Surgery in Patients with Barrett’S Esophagus
Joerg Zehetner*, Steven R. Demeester, Shahin Ayazi, Jesse L. Costales, Florian Augustin, Helen J. Sohn, John C. Lipham, Jeffrey a. Hagen, Tom R. Demeester
Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
Background: Factors associated with progression of Barrett’s to cancer remain unclear, and the impact of medical or surgical therapy on the natural history of Barrett’s remains uncertain. In part this uncertainty is related to the low rate of progression (0.5% per year in the literature) and the long time interval necessary to follow patients to adequately evaluate for progression. The aim of this study was to assess progression of Barrett’s in patients followed long-term after anti-reflux surgery.Methods: A retrospective chart review was performed of all patients with Barrett’s esophagus who underwent anti-reflux surgery from 1989 to 2009. From the 303 patients identified, 75 had follow-up ≥ 5 years (705 patient years) and formed the study group. The fundoplication was classified either as intact or failed based on postoperative endoscopy.Results: Median age in the 75 patients was 54.5 years (range 29-77) and 68% were males. A Nissen fundoplication was used in 87% and a partial fundoplication in 13%. Median follow-up after fundoplication was 8.9 years (range 5-18). Progression of any kind was seen in 8% at a median of 94 months. Progression consisted of Barrett’s to high-grade dysplasia (HGD) in 4 patients, low-grade dysplasia (LGD) to intramucosal cancer (IMC) in 1 patient, and Barrett’s to IMC in 1 patient (Table 1). Regression was seen in 31% of patients, and consisted of loss of dysplasia in one patient with LGD and loss of intestinal metaplasia in 24%. Patients with progression were significantly more likely to have a failed fundoplication (67% vs. 16%, p=0.0129). The risk of progression from Barrett’s to HGD was 0.6% per patient year and from Barrett’s to IMC 0.2%. In patients with a failed fundoplication the risk of progression to HGD/IMC was 2.6% per patient year, compared to 0.36% for those with an intact fundoplication.Conclusion: Compared to established rates for Barrett’s progression in the literature, anti-reflux surgery appears to reduce the risk with long-term follow-up, but only in patients with an intact fundoplication.
Characteristics of Patients with Progression (n=6)
| Patient | Age (years) | Time to HGD/IMC (months) | Initial histology | Final histology | Barrett's length (cm) | Failed fundoplication |
| 1 | 55 | 115 | IM | HGD | 10 | Yes |
| 2 | 51 | 89 | IM | HGD | 6 | Yes |
| 3 | 51 | 98 | IM | HGD | 8 | Yes |
| 4 | 61 | 135 | IM | HGD | 1 | Yes |
| 5 | 61 | 36 | IM | IMC | 1 | No |
| 6 | 62 | 85 | LGD | IMC | 8 | No |
IM (intestinal metaplasia), LGD (low-grade dysplasia), HGD (high-grade dysplasia), IMC (intramucosal cancer)
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