Journal Club

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Journal Club

• Barretts Oesophagus

vs.
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Background

• 50 of the population have reflux symptoms
• 10 develop oesophagitis
• 10 develop complications (ulcer/stricture/Barrett
  s)
• 10 of Barretts develop dysplasia

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Barretts Oesophagus

• Segment of columnar lined oesophagus with
  intestinal metaplasia (goblet cells)
• Acquired
• MalegtFemale
• Explosive increase in prevalence (X60 in 25yrs)
• Time to develop unknown (? 3yrs)
• Long Segment (gt3cm) 3X dysplasia
• Short Segment (lt3cm) 3.5X more prevalent

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Barretts Oesophagus

• Severe reflux symptoms
• Commonly accompanied by oesophagitis / stricture
  / ulceration
• Hiatus hernia
• Low pressure LOS
• Abnormal oesophageal bilirubin exposure

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Dysplasia

• Architectural cytological abns
• Continuum from mild atypia to overt dysplasia
• Severe dysplasia 40 harbour adenoCA
• Sampling Error 4 quad bx at 2cm intervals
• Differentiation from reactive change repeat
  biopsies after medical treatment

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ACG Guidelines

• Barretts Rx reflux then regular surveillance
  endoscopy
• 2 consecutive bx show no dysplasia endoscopy
  every 3 years
• Dysplasia confirm with 2nd pathologist
• Low grade dysplasia yearly endoscopy
• High grade dysplasia rpt endoscopy and bx if
  multifocal high grade consider oesophagectomy

Sampliner RE, Am J Gastoenterol 2002
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Barretts without dysplasia
Medical Treatment

• PPIs - acid production volume
  refluxed
• material - however some reflux still
  occurs
• pH of gastric environment bile acids
  remain in nonpolar (noxious) form
• Up to 34 will develop Barretts

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Barretts without dysplasia
Surgical Treatment

• Fundoplication
• corrects acid duodenal reflux
• ?protects from development of dysplasiaCA
• ?induce regression of Barretts
• de-novo Barretts rare if sx effective

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Journal Search

• MEDLINE 1998 present
• Keyword search Barretts
• Subject found Barrett Esophagus
• Limit by Publication Type Randomised Control
  Trial
• 5 results
• Only one article covering surgical Rx
• COCHRANE Library 2003 Issue 2
• Search Term - fundoplication

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Long-Term Results of a Randomised Prospective
Study Comparing Medical and Surgical Treatment of
Barretts Esophagus

• Parrilla et. al.
• March 2003
• University Hospital , Murcia, Spain

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Study Design

• 1982 2000
• 146 pts with Barretts
• 1982 1997 Long segment only
• 1997 2000 Long and short segment incl.
• Exclusions 25 (long or tight stenosis)
• 8 (rejected
  randomisation)
• Loss to follow-up 12 (rejected surveillance)
• Thus n101

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Methods

• Randomised Control Trial
• Medical treatment arm n43
• Hygiene
• Diet
• Postural measures
• 1982-1991 Ranitidine 150mg bd po
• 1992-2000 Omeprazole 20mg bd po
• Periodic dilatations if stenosis present

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Methods

• Surgical treatment arm n58
• Same surgical team for all cases
• 56 Laparotomy and short Nissen fundoplication
  over a 48-50Fr bougie/ short gastrics divided in
  39 / wrap sutured to the diaphragm / hiatal
  hernias repaired
• 2 Laparotomy and a Collis-Nissen procedure
  for those that had a short intraabdominal length
  of oesophagus / tube of lesser curvature
  fashioned as a substitute for the intra-abdominal
  length of oesophagus

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Clinical Assessment

• Annual interview for both groups
• Same two investigators

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Endoscopic and Histologic Assessment

• Annual endoscopy and biopsies for both groups
• Performed by same endoscopist

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Physiologic Assessment

• All surgically treated had a 24hr pH probe and
  manometric studies at 1 and 5 year post-op or if
  reflux symptoms recurred
• 12/43 medically treated had a 24hr pH probe while
  on medical treatment
• 12 patients from both groups were placed in a
  Bilitec group assessing for biliary and duodenal
  reflux at 12 months post treatment

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Statistical Analysis

• Student t test quantitative variables
• Chi-square Pearson test qualitative variables

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Clinical Results

• Medical Rx
• 91 - minimal or no reflux sx
• 9 - sx improved but persistent needing Rx
• Surgical Rx
• 91 - minimal or no reflux sx
• 7 - sx improved but persistent needing Rx
• 2 - poor sx control

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Clinical Results

• Surgical Morbidity
• Mild transient dysphagia 29
• Inability to belch or vomit 22
• Splenectomy 2

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Physiologic Results

• Medical Rx
• Significant decrease in total time pHlt4
• 25 - pathologic rates of acid reflux
• 75 - pathologic rates of biliopancreatic reflux
  (ie 9/12 patients in Bilitec subgroup)

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Physiologic Results

• Surgical Rx
• Significant decrease in total time pHlt4
• 15 - pathologic rates of acid reflux
• 8 - pathologic rates of biliopancreatic reflux
  (ie 1/12 patients in Bilitec subgroup)

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Endoscopic and Histologic Results

• Disappearance of Barretts was not demonstrated
  in any case
• No significant difference in rates of progression
  from Barretts to dysplasia or adenocarcinoma

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Endoscopic and Histologic Results

• Medical Rx
• 20 developed dysplasia de novo
• ¼ of these were high grade
• Surgical Rx
• 6 developed dysplasia de novo
• 3/5 of these were high grade
• All these correlated with pts who had clinical
  and functional recurrence of reflux ie failed
  surgery
• Successful Surgical Rx Subgroup (49/58)
• 2 developed dysplasia de novo (1/44)
• This was a statistically significant difference
  to the medical Rx group (P lt 0.05)
• No case of high grade dysplasia nor malignancy

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Discussion

• Surgery prevents both acid and duodenal reflux ?
  Role in Barretts progression
• Clinically no difference between the two groups
  in symptom relief
• Endoscopic data also showed surgery more
  efficient for curing associated inflammatory
  lesions

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Discussion

• Surgery failed in 9/58 (15)
• Successful surgery significantly reduced the risk
  of Barretts progressing to dysplasia and
  adenocarcinoma
• ?Validity of comparing all medical Rx group to a
  successful surgery subgroup
• - introduces bias
• - ?successful medical group
• However, this observation should not be
  ignoredsupports concept that eliminating reflux
  prevents progression to neoplasia

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Thank You