Long-term outcome of antireflux surgery in patients with Barrett's esophagus

Objective To assess the long-term outcome of antireflux surgery in patients with Barr ett's esophagus. Summary Background Data The prevalence of Barrett's esophagus is increasing, and its treatment is p roblematic. Antireflux surgery has the potential to stop reflux and induce a quiescent mucosa. Its long-term outcome, however, has recently been chall enged with reports of poor control of reflux and the inability to prevent p rogression to cancer. Methods The outcome of antireflux surgery was studied in 97 patients with Barrett's esophagus. Follow-up was complete in 88% (85/97) at a median of 5 years. F ifty-nine had long-segment and 26 short-segment Barrett's. Patients with in testinal metaplasia of the cardia were excluded. Fifty patients underwent a laparoscopic procedure, 20 a transthoracic procedure, and 3 abdominal Niss en operations. Nine had a Collis-Belsey procedure and three had other parti al wraps. Outcome measures included relief of reflux symptoms (all), patien ts' perception of the result (all), upper endoscopy and histology (n = 79), and postoperative 24-hour pH monitoring (n = 21). Results At a median follow-up of 5 years, reflux symptoms were absent in 67 of 85 p atients (79%). Eighteen (20%) developed recurrent symptoms; four had return ed to taking daily acid-suppression medication. Seven patients underwent a secondary repair and were asymptomatic, increasing the eventual successful outcome to 87%. Recurrent symptoms were most common in patients undergoing Collis-Belsey (33%) and laparoscopic Nissen (26%) procedures and least comm on after a transthoracic Nissen operation (5%). The results of postoperativ e 24-hour pH monitoring were normal in 17 of 21 (81 %). Recurrent hiatal he rnias were detected in 17 of 79 patients studied; 6 were asymptomatic. Seve nty-seven percent of the patients considered themselves cured, 22% consider ed their condition to be improved, and 97% were satisfied. Low-grade dyspla sia regressed to nondysplastic Barrett's in 7 of 16 (44%), and intestinal m etaplasia regressed to cardiac mucosa in 9 of 63 (14%). Low-grade dysplasia developed in 4 of 63 (6%) patients. No patient developed high-grade dyspla sia or cancer in 410 patient-years of follow-up. Conclusions After antireflux surgery, most patients with Barrett's enjoy long-lasting r elief of reflux symptoms, and nearly all patients consider themselves cured or improved. Mild symptoms recur in one fifth. Importantly, dysplasia regr essed in nearly half of the patients in whom it was present before surgery, intestinal metaplasia disappeared in 14% of patients, and high-grade dyspl asia and adenocarcinoma were prevented in all.