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Antireflux Surgery for Control of Reflux and Protection of the Neosquamous Mucosa After Endoscopic Therapy
Stephanie G. Worrell*, Joseph D. Dixon, Steven R. Demeester
Keck School of Medicine of Univeristy of Southern California, Los Angeles, CA
Introduction: Barrett's esophagus develops as a consequence of gastroesophageal reflux, and after mucosal resection or ablation control of reflux may be important to prevent recurrence of Barrett's. The aim of this study was to evaluate the efficacy of an antireflux operation for preventing recurrence of intestinal metaplasia after endoscopic therapy for dysplastic Barrett's or superficial esophageal adenocarcinoma.
Methods: A retrospective chart review was performed of all patients that underwent antireflux surgery after endoscopic therapy for Barrett's esophagus (BE) or superficial esophageal adenocarcinoma.
Results: There were 9 patients, 6 males and 3 females, with a median age of 70 years. All patients had a Nissen fundoplication after complete resection and/or radiofrequency ablation (RFA) of all intestinal metaplasia had been accomplished. Ablation was performed after endoscopic mucosal resection for intramucosal cancer and BE in 5 patients and for BE with high grade dysplasia in 4 patients. Patients had a median of 2 ablations (range 1-5) prior to complete eradication. The median time from eradication of all intestinal metaplasia to Nissen fundoplication was 8 months. The median follow-up since fundoplication was 22 months. In 8 patients a follow-up endoscopy has been done and 75% (6/8) have remained free of intestinal metaplasia. There were two patients with recurrent BE that was eradicated with a single additional ablation and are currently in remission. Two patients were noted to have a small recurrent hernia on surveillance endoscopy and one of these patients had recurrent intestinal metaplasia.
Discussion: Antireflux surgery after RFA may augment the durability of the ablation treatment. In our study 75% of patients remained free of metaplasia or dysplasia at a median of 22 months after Nissen fundoplication. The addition of an antireflux operation to the ablative treatment of metaplasia or dysplasia may offer the best long-term control of reflux and preservation of the neosquamnous mucosa.
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