Management of Barrett's Esophagus
Barrett's esophagus or intestinal metaplasia is defined as the replacement of the normal esophageal stratified squamous epithelium with any length of endoscopically visible columnar epithelium that on biopsy demonstrates acid-mucin containing goblet cells (i.e. intestinal metaplasia). It is estimated to develop in 10-20% of patients with chronic gastroesophageal reflux disease (GERD). Middle aged white males are at highest risk. The clinical significance of Barrett's esophagus lies in its relationship with adenocarcinoma of the esophagus. The risk of developing esophageal cancer in patients with Barrett's esophagus is about 0.5-1% per year
Symptoms and Diagnosis
Patients with Barrett's esophagus may experience the typical symptoms of GERD (i.e. heartburn, regurgitation, dysphagia), atypical symptoms of GERD (i.e. asthma, cough, repeated pneumonia, chest pain), or may be relatively asymptomatic. Because heartburn is so common in the general population, the symptoms may be ignored by patients or their physicians until serious complications develop. Barrett's esophagus can develop despite symptomatic control of GERD; therefore all patients who require long term medical therapy should be considered for Endoscopic evaluation to detect the development of Barrett's metaplasia. Diagnosis of Barrett's metaplasia requires biopsy of the columnar mucosa. To exclude the presence of dysplasia in Barrett's, current recommendations include multiple biopsies taken in a systematic fashion throughout the entire length of columnar mucosa.
The goals of treatment of Barrett's esophagus in the absence of dysplasia are essentially the same as for uncomplicated GERD: 1) control of symptoms and 2) prevention of gastroesophageal reflux (which may also reduce the risk of the development of, or progression to, dysplasia and adenocarcinoma). Therapeutic options include medical therapy with proton pump inhibitors, H-2 receptor antagonists, and/or prokinetic agents, or a surgical antireflux procedure. There are advantages and disadvantages of each. Medical therapy is directed at acid suppression. It is non-invasive and is effective at controlling reflux symptoms and maintaining the healing of esophagitis. However, many patients treated medically will continue to demonstrate reflux on pH testing, which may contribute to the development of dysplasia and adenocarcinoma.
Surgical antireflux therapy effectively controls the symptoms of reflux, prevents both acid and non-acid reflux, and has been shown to be superior to medical therapy in several prospective studies for the treatment of GERD. There is suggestive evidence that antireflux surgery may halt the progression of Barrett's esophagus to dysplasia and adenocarcinoma more effectively than medical therapy; this remains controversial. Fundoplication is the surgical procedure of choice for control of gastroesophageal reflux. Fundoplication can usually be accomplished using minimally invasive techniques, which require a short hospital stay and convalescence. Serious complications are rare.
Because the abnormal mucosa generally does not disappear with treatment, patients with documented Barrett's esophagus should have surveillance endoscopy and biopsy every 2 years, regardless how the underlying GERD is treated. Because inflammation can be confused with dysplasia, patients demonstrating low-grade dysplasia should be treated with intensive medical therapy with the goal of complete acid suppression, then re-biopsied at approximately 3 months. If low-grade dysplasia is confirmed, surveillance should be performed annually to rule out progression to high-grade dysplasia and/or cancer. If high-grade dysplasia is detected and confirmed, such patients should be referred to a center with expertise in esophageal resection, since there is a high likelihood of occult cancers in these patients.
There are several innovative techniques designed to ablate or excise the abnormal mucosa. These include photodynamic therapy, other energy sources, or excisional techniques. There are studies that have documented reversal of Barrett's metaplasia to squamous epithelium, but no studies to date have documented that this results in a decreased risk of adenocarcinoma. In addition, squamous mucosa may regrow over incompletely eradicated columnar mucosa, rendering it endoscopically invisible without abolishing the risk of malignant transformation. These techniques should be considered experimental at this time as data are being accumulated regarding the efficacy and complications associated with each of them. At this time, these investigational non-operative therapies should be reserved for patients with high grade dysplasia who pose significant operative risks. Their role, in comparison to surgery, for the management of patients with high grade dysplasia will be clarified by further study.
Risks and Expected Outcomes
The most common risks associated with open or laparoscopic antireflux operations include bleeding or damage to structures such as the spleen, vagus nerves, esophagus or stomach. These complications occur at a rate of less than 5%. Respiratory complications, such as atelectasis or pneumonia, are less frequent after laparoscopic surgery than after open upper abdominal surgery.
Most patients will experience temporary difficulty in swallowing after surgery, especially with solid foods, but nearly all patients are able to swallow normally and eat an unrestricted diet by six weeks after surgery. A feeling of fullness (satiety) is another common but temporary occurrence. Gas-bloat syndrome, a sensation of bloating associated with inability to belch, may occur after fundoplication. Prior to surgery, in a subconscious effort to neutralize refluxed gastric acid with saliva, many patients with reflux esophagitis swallow frequently. Persistent aerophagia after surgery may cause bloating and increased flatus. The majority of patients require a hospital stay of 1-3 days after laparoscopic fundoplication, or 3-5 days after an open operation. Hospitalization may be prolonged in the presence of other comorbid conditions or postoperative complications. Data suggest that long-term outcome is equivalent after open or laparoscopic procedures, with relief of reflux symptoms equivalent to that achieved with optimal medical therapy. Recurrent symptoms should be investigated for cause, and appropriate medical or surgical treatment determined.
Surveillance of the Barrett’s mucosa should continue after surgical therapy. Endoscopy every two to three years with four quadrant biopsies at 2 cm intervals in the Barrett’s mucosa is needed.
The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for Barrett’s esophagus or reflux esophagitis. Antireflux surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of gastroesophageal reflux disease. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the esophagus and stomach. When performing laparoscopic fundoplication, it is highly desirable that the surgeon has advanced laparoscopic skills. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery is important to assess.
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Board Approved 10/7/02
Key Words - Barrett's esophagus, gastroesophageal reflux, GERD, dysplasia, fundoplication, patient, guideline
SSAT Patient Care Committee Guidelines
These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.
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