Endoscopic surveillance of columnar-lined esophagus - Frequency of intestinal metaplasia detection and impact of antireflux surgery

Objective To quantify the occurrence of intestinal metaplasia in columnar-l ined esophagus (CLE) during endoscopic surveillance and to evaluate the imp act of antireflux surgery on the development of intestinal metaplasia. Summary Background Data The malignant potential in segments of CLE is mainl y restricted to those containing intestinal metaplasia. Patients with segme nts of CLE in which no intestinal metaplasia can be detected are rarely enr olled in a surveillance program but may still be at increased risk of devel oping esophageal adenocarcinoma because intestinal metaplasia may be missed or may develop with time. Methods The occurrence of intestinal metaplasia on biopsy samples was deter mined on repeated endoscopies in 177 patients enrolled in a surveillance pr ogram for CLE. The incidence of intestinal metaplasia in patients with no e vidence of intestinal metaplasia on the two first endoscopies was evaluated on the subsequent endoscopies and compared in patients with medically and surgically treated gastroesophageal reflux disease. Results Intestinal metaplasia was found in 53% of the patients (94/ 177) on their first surveillance endoscopy and was more prevalent in long segments of CLE. The prevalence of intestinal metaplasia increased markedly with in creasing number of surveillance endoscopies. Intestinal metaplasia tended t o be detected early in patients with long segments of CLE; in patients with shorter segments, intestinal metaplasia was also detected late in the cour se of endoscopic surveillance. Patients with surgically treated reflux dise ase were 10.3 times less likely to develop intestinal metaplasia compared w ith a group receiving standard medical therapy. Conclusion Biopsy samples from a single endoscopy, despite an adequate biop sy protocol, are insufficient to rule out the presence of intestinal metapl asia. Patients in whom biopsy specimens from a segment of CLE show no intes tinal metaplasia have a significant risk of having undetected intestinal me taplasia or of developing intestinal metaplasia with time. Sampling error i s probably the reason for the absence of intestinal metaplasia in segments of CLE longer than 4 cm, whereas development of intestinal metaplasia is co mmon in patients with shorter segments of CLE. Antireflux surgery protects against the development of intestinal metaplasia, possibly by better contro l of reflux of gastric contents.