The Fate of Barrett's Epithelium Under Acid Suppression Obtained by Medical or Surgical Therapy
Renato Salvador*1, Paola Parente3, Nicola Passuello1, Mario Costantini1, Lisa Zanatta1, Tieppo Chiara1, Loredana Nicoletti1, Francesco Cavallin4, Fabio Farinati1, Ermanno Ancona1, Massimo Rugge2, Giovanni Zaninotto2
1Department of Surgical and Gastroenterological Sciences, Clinica Chirurgica I, University of Padova, Padua, Italy; 2Department of General Surgery, SS Giovanni e Paolo Hospital, ULSS 12, Venice, Italy; 3Department of Medical Diagnostic Sciences & Special Therapies, Pathology Unit, University of Padova, Padova, Italy; 4Surgical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy
Background: Barrett’s Epithelium (BE) is the most serious complication of GERD and it is associated with an increased risk to develop adenocarcinoma. Anecdotal BE regression after profound acid suppression have been reported. The aim of the study was to evaluate the modifications induced by surgical and medical therapy on clinical findings, phenotype of BE and expression of the Cdx2 protein, as a gene involved in the metaplastic differentiation. Patients and Methods: 89 Barrett’s patients with a follow-up endoscopy performed at least 12 months after surgery or medical therapy were enrolled. Group A (n=45) received antireflux surgery Group B (n=44) medical therapy. Patient symptoms were evaluated using a detailed questionnaire; endoscopy with biopsy was performed according to Seattle; histologic assessment. of BE phenotype modifications induced by therapy (presence of I.M., type of I.M., expression of Cdx2) were quantified by means of histology (H&E), histochemistry (HID) and himmunohistochemistry. Barium swallow, manometry and 24-h pH were performed pre and 6 months after surgery. Surgical failures were defined as: (1) abnormal 24-h pH monitoring; (2) recurrence of endoscopic esophagitis; (3) recurrence of hiatal hernia/slipped fundoplication at endoscopy/barium swallow.Results: The median of follow up was 34 months (IQR 23-48). The symptom score decreased after both therapies: 14.5 (10-21) pre vs 0 (0-6) post (p=0.0001). The decrease of endoscopic length of BE was more significant in group A than in group B (p=0.006), and generally BE length decreased more in patients with short segment BE (SSBE, < 3cm BE), than in those with long segment BE (LSBE, ≥ 3 cm BE), (p=0.02). Regression of I.M. was observed in 12 of 89 patients after therapy: all cases occurred in SSBE patients. In patients in which I.M. was no longer evident after therapy, Cdx2 expression was also absent. Two SSBE patients had recurrence of reflux after surgery. In the 13 SSBE patients in whom surgery was effective BE regression was observed in 7, significantly different from the medical group. (p=0.02).Conclusions: Medical and Surgical therapies are both effective in controlling GERD symptoms. Patients with SSBE (but not LSBE) may regress with adequate acid suppression. Surgery - when effective- leads to regression more frequently than medical treatment.
Back to 2011 Program
