A NEW PHYSIOLOGICAL APPROACH FOR THE SURGICAL-TREATMENT OF PATIENTS WITH BARRETTS-ESOPHAGUS - TECHNICAL CONSIDERATIONS AND RESULTS IN 65 PATIENTS

Objective To determine the results of a new surgical procedure for pat ients with Barrett's esophagus. Summary Background Data In addition to pathologic acid reflux into the esophagus in patients with severe gas troesophageal reflux and Barrett's esophagus, increased duodenoesopheg eal reflux has been implicated. The purpose of this study was to estab lish the effect of a new bile diversion procedure in these patients. M ethods Sixty-five patients with Barrett's esophagus were included in t his study. A complete clinical, radiologic, endoscopic, and bioptic ev aluation was performed before and after surgery. Besides esophageal ma nometry, 24-hour pH studies and a Bilitec test were performed. After s urgery, gastric emptying of solids, gastric acid secretion, and serum gastrin were determined. All patients underwent highly selective,vagot omy, antireflux procedure (posterior gastropexy with cardial calibrati on or fundoplication), and duodenal switch procedure, with a Roux-en-Y anastomosis 60 cm in length. Results No deaths occurred. Morbidity oc curred in 14% of the patients. A significant improvement in symptoms, endoscopic findings, and radiologic evaluation was achieved. lower eso phageal sphincter pressure increased significantly (p < 0.0001), as di d abdominal length and total length of the sphincter (p < 0.0001). The presence of an incompetent sphincter decreased from 87.3% to 20.9% (p < 0.0001). Three of seven patients with dysplasia showed disappearanc e of this dysplasia. Serum gastrin and gastric emptying of solids afte r surgery remained normal. Basal and peak acid output values were low. Twenty-four hour pH studies showed a mean value of 24.8% before surge ry, which decreased to 4.8% after surgery (p < 0.0001). The determinat ion of the percentage time with bilirubin in the esophagus was 23% bef ore surgery; this decreased to 0.7% after surgery (p < 0.0001). Late r esults showed Visick I and II gradation in 90% of the patients and gra de III and IV in 10% of the patients. Conclusions This physiologic app roach to the surgical treatment of patients with Barrett's esophagus p roduces a permanent decrease of acid secretion (and avoids anastomotic ulcer), decreases significantly acid reflux into the esophagus, and a bolishes duodenoesophageal reflux permanently. Significant clinical im provement occurs, and dysplastic changes at Barrett's epithelium disap pear in almost 50% of the patients.