Long-term clinical and pathologic response of Barrettʹs esophagus after antireflux surgery

Background The impact of antireflux surgery on outcome in Barrettʹs esophagus, in particular its effect on both the regression of metaplasia and the progression of metaplasia through dysplasia to adenocarcinoma, remains unclear. This long-term follow-up study evaluated clinical, endoscopic, histopathologic, and physiologic parameters in patients with Barrettʹs esophagus who underwent antireflux surgery in a specialist unit. Methods Between 1985 and 2001, 58 patients with Barrettʹs esophagus (49 long-segment and 9 short-segment) underwent a Rossetti-Nissen fundoplication, 32 via open procedure and 26 laparoscopically. Symptomatic follow-up with a detailed questionnaire was available in 58 (100%) and follow-up endoscopy and histology in 57 (98%) patients, and 41 patients (71%) underwent preoperative and postoperative 24-hour pH monitoring. Results At a median follow-up of 59 months, 52 patients (90%) had excellent symptom control, whereas 6 patients (10%) had significant recurrent symptoms and were on regular proton pump inhibitor medication. Seventeen of 41 patients having preoperative and postoperative pH monitoring (41%) had a persistent increase of acid reflux above normal. Thirty-five percent (20 of 57) of patients showed either partial or complete regression of Barrettʹs epithelium. Six of 8 patients with preoperative low-grade dysplasia showed evidence of regression. Dysplasia developed after surgery in 2 patients, and 2 patients developed adenocarcinoma at 4 and 7 years after surgery. All 4 of these patients had abnormal postoperative acid scores. Conclusions Nissen fundoplication provides excellent long-lasting relief of symptoms in patients with Barrettʹs esophagus and may promote regression of metaplasia and dysplasia. Control of symptoms does not concord fully with abolition of acid reflux. Progression of Barrettʹs to dysplasia and tumor was only evident in patients with abnormal postoperative acid scores, suggesting that pH monitoring has an important role in the follow-up of surgically treated patients.