Risk Factors for Developing of Esophageal Adenocarcinoma After Antireflux Surgery
Hedvig E. LöFdahl*, Yunxia Lu, Pernilla Lagergren, Jesper Lagergren
Department of molecular medicine and surgery, Karolinska Institutet, Stockholm, Sweden
Background
The incidence of esophageal adenocarcinoma has increased more rapidly than that any other solid tumor in several western populations. The main risk factors are gastroesophageal reflux and obesity, while tobacco smoking is a moderate risk factor. No certain protective effect has been shown from antireflux surgery. We hypothesized that patients who despite antireflux surgery develop esophageal adenocarcinoma more than 5 years after such surgery more often have recurrent reflux or are more often exposed to the other risk factors, compared to patients who do not develop this cancer after antireflux surgery.
Methods
A case-control study was nested within a cohort of all patients in Sweden who had undergone antireflux surgery during 1965-2006 according to the Swedish Patient Register. The cases were patients who developed adenocarcinoma of the esophagus or gastroesophageal junction at least 5 years after antireflux surgery as identified in the Swedish Cancer Register. The controls were matched to the cases regarding age, sex, and calendar-year of the antireflux surgery. Information about the study variables recurrent reflux, type of antireflux surgery, body mass index (BMI), and tobacco smoking status was collected through review of medical records, where the reviewer was kept blinded to the case-control status. Relative risk, expressed as odds ratio (OR) with 95% confidence interval (CI), was calculated through multivariable conditional logistic regression, adjusted for the study variables.
Results
Included were 39 cases and 133 controls. Recurrent reflux was followed by an adjusted 3-fold increased the risk of esophageal adenocarcinoma compared to those without reflux symptoms after antireflux surgery (OR 3.1, 95% CI 1.3-7.3). There were no statistically significant differences in risk comparing total with partial fundoplicatio (OR 0.9, 95% CI 0.4-2.2), BMI over 30 with BMI lower than 25 (OR 1.5, CI 0.4-5.5) or current smoking with non-smoking (OR 1.2, 95% CI 0.5-2.8).
Conclusion
Recurrence of reflux after antireflux surgery seems to be a key factor in explaining the lack of any clear protective effect of antireflux surgery regarding risk of esophageal adenocarcinoma.
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