Antireflux Surgery for Dysplastic Barrett’s Esophagus

Excerpt

Nearly a decade ago I came home from DDW with scars on my ego, having been scolded by gastroenterologists for touting the ability of laparoscopic fundoplication to protect patients with Barrett’s esophagus from the ravages of esophageal cancer. As high volume laparoscopic antireflux surgeons with many Barrett’s patients treated, quite a number of us (Hunter, Pellegrini, Peters, Oberg, and others) had observed and reported extremely low rates of cancer development in our Barrett’s patients under annual surveillance after fundoplication, rates much lower than medical surveillance studies of patients on PPIs. As a result of this intellectual dissonance, I challenged Eugene Chang, an extremely bright surgical resident at our institution to answer the question: Does laparoscopic fundoplication protect against cancer in patients with Barrett’s esophagus? The result was a very well performed systematic review of the literature, with a mixed message [1]. All in, Barrett’s patients were less likely to develop cancer after fundoplication, BUT the literature was dominated by case series—such as ours—where selection bias may have favored younger, healthier patients with short segment Barrett’s, excellent compliance with care recommendations, and less endstage physiology (strictures, motor disorders, giant hernias, etc.). When we looked at RCT’s (1) and case-controlled series (4) we could not demonstrate a difference. It was no longer clear that fundoplication prevented the progression of Barrett’s esophagus to cancer. So with my tail between my legs, I changed my tune… but only a little. …