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The Durability of Endoscopic Therapy for Treatment of Barrett's Metaplasia, Dysplasia and Mucosal Cancer After Nissen Fundoplication
Corey Johnson*1, Brian E. Louie1, Christy M. Dunst2, Steven R. Demeester3, Michal J. Lada5, Jeffrey H. Peters5, Ralph W. Aye1, Alexander S. Farivar1, Joe Dixon4,3, Stephanie G. Worrell3, Jessica Reynolds4, Aaron Willie2, John Lipham4
1Swedish Cancer Institute, Swedish Medical Center, Seattle, WA; 2General and Minimally Invasive Surgery, The Oregon Clinic, Portland, OR; 3Division of Thoracic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA; 4Division of Upper GI and General Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA; 5Division of Thoracic Surgery, University of Rochester School of Medicine, Rochester, NY
INTRODUCTION: Radiofrequency ablation (RFA) with or without endoscopic resection (EMR) is an established treatment strategy for Barrett's metaplasia, dysplasia and mucosal cancer. During and after endotherapy, most patients are managed with proton pump inhibitors at maximal daily doses. The incidence of recurrent Barrett's metaplasia, dysplasia or cancer after complete eradication is reported at 28% at 2.2 years of follow up using this strategy. Theoretically, fundoplication may offer better control of GERD thus possibly influencing the recurrence of Barrett's metaplasia. We hypothesize the addition of fundoplication should result in a lower recurrence rates after complete eradication.
METHODS: Multi-institutional retrospective review of patients undergoing endotherapy followed by fundoplication
RESULTS: A total of 49 patients underwent RFA +/- EMR followed by Nissen fundoplication. The mean age was 61 years with 40 males and a BMI of 29.8. All but 1 patient was Caucasian. The median Barrett's length was 5.5 cm. Hiatal hernias were seen in 98% with a mean size of 3 cm. Entry histology was non-dysplastic Barrett's (NDBE, 8%), low grade dysplasia (LGD, 16%), high grade dysplasia (HGD, 51%) and intramucosal cancer (IMC, 24%). Multilevel dysplasia was found in 16 patients (33%), and raised or nodular histology in 17 patients (35%). The average duration of symptoms prior to fundoplication was 220 months.
EMR was performed in 53% followed by 3.7 RFA treatments (range 1-11) with 44/49 achieving complete eradication. Five patients did not achieve remission: one had persistent Barrett's, 2 patients had HGD eradicated with persistent NDBE, 1 patient had intramucosal cancer eradicated with persistent NDBE, and 1 patient had LGD on entry with no further biopsy results available. Five patients (10%) had strictures after RFA. A total of 9/49 (18%) patients required a Collis gastroplasty to achieve adequate intra-abdominal esophageal length. Fundoplication was done on average 8 months after eradication of dysplasia.
At 32 months mean follow-up after complete eradication, 12 patients had recurrent disease. Of these, 9/44 (20.5%) occurred after fundoplication and 3 recurred prior to fundoplication. Of the post-fundoplication recurrences, 6 had HGD on entry pathology with only Barrett's on recurrence, 2 had LGD on entry with Barrett's on recurrence, and one had LGD on entry and on recurrence.
Conclusion: In patients who undergo fundoplication after RFA +/- EMR for Barrett's metaplasia , dysplasia, or intramucosal cancer, the rate of recurrence at a mean follow-up of 32 months is 20.5%. This rate appears superior to RFA +/- EMR combined with medical management alone in patients with more advanced entry pathology. Moreover, only one patient developed a recurrence after fundoplication that progressed beyond NDBE and none developed esophageal cancer.
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