Barrett's esophagus: A surgical disease

Barrett's metaplasia can develop in patients with gastroesophageal reflux d isease (GERD), and metaplasia can evolve into dysplasia and adenocarcinoma. The optimal treatment for Barrett's metaplasia and dysplasia is still bein g debated. The study reported herein was designed to assess the following: (1) the incidence of Barrett's metaplasia among patients with GERD; (2) the ability of laparoscopic fundoplication to control symptoms in patients wit h Barrett's metaplasia; (3) the results of esophagectomy in patients with h igh-grade dysplasia; and (4) the character of endoscopic follow-up programs of patients with Barrett's disease being managed by physicians throughout a large geographic region (northern California). Five-hundred thirty-five p atients evaluated between October 1989 and February 1997 at the University of California San Francisco Swallowing Center had a diagnosis of GERD estab lished by upper gastrointestinal series, endoscopy, manometry, and pH monit oring. Thirty-eight symptomatic patients with GERD and Barrett's metaplasia underwent laparoscopic fundoplication. Eleven other consecutive patients w ith high-grade dysplasia underwent transhiatal esophagectomies. Barrett's m etaplasia was present in 72 (13%) of the 535 patients with GERD. The follow ing results were achieved in patients who underwent laparoscopic fundoplica tion (n = 38): Heartburn resolved in 95% of patients, regurgitation in 93% of patients, and cough in 100% of patients. With regard to transhiatal esop hagectomy (n = 11), the average duration of the operation was 339 +/- 89 mi nutes. The only significant complications were two esophageal anastomotic l eaks, both of which resolved without sequelae. Mean hospital stay was 14 +/ - 5 days. There were no deaths. The specimens showed high-grade dysplasia i n seven patients and invasive adenocarcinoma (undiagnosed preoperatively) i n four (36%). These results can be summarized as follows: (1) Barrett's met aplasia was present in 13 % of patients with GERD being evaluated at a busy diagnostic center; (2) laparoscopic fundoplication was highly successful i n controlling symptoms of GERD in patients with Barrett's metaplasia; (3) i n patients with high-grade dysplasia esophagectomy was performed safely (in vasive cancer had eluded preoperative endoscopic biopsies in one third of t hese patients); and (4) even though periodic endoscopic examination of Barr ett's disease is universally recommended, this was actually done in fewer t han two thirds of patients being managed by a large number of independent p hysicians in this geographic area.