Barrett’s Esophagus
A. Darrell Tackett, MD, FACS
Gastroesophageal reflux disease (GERD) is one of the most common afflictions of modern man. In a large study population, 11% of adults reported daily heartburn symptoms with an additional 27% reporting weekly to monthly symptoms. Barrett’s Esophagus (BE), metaplastic conversion of the squamous epithelium of the esophagus to columnar epithelium, is identified in 10% to 20% of patients who undergo endoscopy because of reflux symptoms. Since patients with BE have a 30 to 125 fold increased risk of developing adenocarcinoma of the esophagus, it represents a significant risk of loss of life to a large segment of the population.
BE is usually considered a non regressive condition with no well-documented reports of reversal of the condition even with successful medical or surgical anti-reflux treatment. The role of exposure of the esophageal squamous mucosa to duodenal contents in the development of BE and adenocarcinoma of the esophagus has recently been emphasized.  At present, anti-reflux surgery is the only effective treatment that prevents the reflux of both gastric and duodenal contents. Aggressive medical treatment with H2 blockers and proton-pump inhibitors will resolve symptoms in a large number of GERD patients but leaves the distal esophagus exposed to duodenal reflux.
Partial restoration of squamous epithelium after ablation of Barrett’s metaplasia with laser or photodynamic therapy has been reported. However, in the presence of continued reflux even with effective omeprazole therapy, reappearance of BE and even adenocarcinoma have been reported in those patients initially successfully treated with ablative therapy.
In the January issue of the “Annals of Surgery”, Salo et al, from the Department of Thoracic Surgery, Helsinki Central University Hospital, Helsinki, Finland reported a series of 17 patients with GERD and BE. Sixteen patients underwent a “floppy” fundoplication and one patient who had two prior unsuccessful fundoplications underwent a Roux-en-Y gastrojejunostomy to divert intestinal contents away for the distal esophagus. Follow-up pH monitoring studies showed a reduction of time of exposure to pH<4 in the distal esophagus from an average of 21.9% preoperatively to an average of 0.9% postoperatively indicating a successful anti-reflux surgery. Eleven of the patients underwent laser ablation of the BE with essentially complete resolution of the BE on follow-up endoscopy. Continued follow-up for an average of 26 months (range 6-52 months) confirmed replacement of the intestinal metaplasia of the entire tubular esophagus with squamous mucosa with no recurrence of BE. The control group without laser ablation did not show any change in the preoperative extent of BE. This study clearly shows that in a reflux free environment created by anti-reflux surgery, the regenerated esophageal mucosa arising after ablation of Barrett’s metaplasia with endoscopic laser energy is of squamous type. When compared to the reported series of patients in the literature treated with ablation, but with continued reflux despite good medical management, the conversion to squamous epithelium appears to be durable over time.
Fundoplication, either of the Nissen or Toupet type, has been shown to satisfactorily resolve esophageal reflux in 85% of patients whether done by the open technique or more recently using laparoscopic procedures. In recent years, the noninvasive nature of the laparoscopic fundoplication has made the procedure an increasingly attractive alternative to long term medical management of GERD. Barrett’s Esophagus, the most life threatening complication of GERD, can be converted to benign squamous mucosa by the judicious application of endoscopic laser ablation. In the presence of a reflux free environment, this combination of treatment modalities may help resolve a previously resistant and potentially deadly problem.
Williamson, et al, Annals of Thoracic Surgery 1990;49:537-42 Salo et al, Annals of Surgery 1998;227:40-45 |
