Results of antireflux surgery in patients with Barrett's esophagus
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BACKGROUND: Barrett's esophagus (BE) is defined as the presence of intestinal metaplasia with goblet cells, which replace the normal squamous epithelium of the distal esophagus. PURPOSE: To review the results of surgical treatment in patients with short- and long-segment BE. METHODS: Between 1980 and 2006, a total of 35 articles published in English literature dealing with surgical treatment of patients with BE were reviewed. Clinical success, stop of acid, and duodenal reflux into the distal esophagus, endoscopic and histologic evaluations and development of adenocarcinoma were the main issues included. RESULTS: The majority of publications include very few patients (less than 50), the follow-up is less than 5 years in 80% and classic antireflux surgery obtains clinical success before 5 years of follow-up in 81% of the patients, but this success deteriorates with the length of follow-up. Acid reflux before and after surgery was evaluated in few publications and duodeno-esophageal reflux in only 3 papers. The majority of reports include only 1 endoscopic evaluation after surgery while histologic analysis of Barrett's mucosa has shown regression of intestinal metaplasia in only 5%. Progression of adenocarcinoma has been reported in 3.8%, even in asymptomatic patients. On the contrary, the acid suppression and duodenal diversion procedure obtained 91% of clinical success at a late follow-up (8 to 10 years), permanent control of acid and duodenal reflux, regression of intestinal metaplasia to cardiac mucosa in 55% of the patients and no progression to high grade dysplasia or adenocarcinoma has been documented. Patients with short-segment BE have shown very good results after laparoscopic fundoplication. CONCLUSIONS: Antireflux surgery in patients with long-segment BE does not prevent the development of adenocarcinoma. Acid suppression and duodenal diversion procedure is an alternative procedure, specially in patients below 60 years of age.