[The influence of Barrett's esophagus on the clinical signs and postoperative results of GERD]

Z Endzinas, A Mickevicius, M Kiudelis
Zentralblatt Für Chirurgie 2004, 129 (2): 99-103

AIM OF THE STUDY: Was to estimate the influence of the Barrett's esophagus on the clinical signs and post-surgical results of the GERD.

PATIENTS AND METHODS: Within 1998-2001 193 patients have been operated upon in our clinic due to GERD, 81 male and 112 female. Mean patient age was 55 years (from 16 to 84 years). All patients had complaints on heartburn and regurgitation. We assessed the severity of heartburn, regurgitation, dysphagia with the help of a special scale ranging from 1 (absence of symptoms) to 5 (most severe symptoms). All patients underwent gastric and esophageal radiological investigation with barium contrast as well as esophago-gastro-duodenoscopy (EGDS) with biopsy. In 190 cases esophageal hernia was found. The reflux-esophagitis was classified according to Savary-Miller after endoscopic examination. Esophagitis of degree I-III was diagnosed presurgically in 176 cases, Barrett's esophagus in 16 (9.1%) cases. In 13 cases we found a short metaplastic segment (< 3 cm), in 3 cases a long segment (> 3 cm). In 15 cases we found metaplasia without dysplasia, in 1 case low-grade dysplasia. In order to assess the presence of BM influence on presurgical clinical signs, the severity of esophagitis, and the regression rate of symptoms after surgery, we divided the patients into two groups and compared them: group I (with Barrett's metaplasia), and group II (without Barrett's metaplasia). All patients underwent laparoscopic Nissen or Toupet fondoplications. For group I patients we performed 14 Nissen and 2 Toupet procedures, in group II 148 Nissen and 29 Toupet interventions. The regression of clinical and endoscopic symptoms was assessed 6 months after surgery by re-questioning the patients and with the help of EGDS. In cases of Barrett's esophagus endoscopic biopsies from all 4 esophageal segments were performed. The patients of group I were followed-up by performing EGDS every 6 months. The mean follow-up period after surgery was 28 months.

RESULTS: No statistically significant difference was found when comparing the groups for age (group I--59/SD 11, and group II--54/SD 13.2), gender, disease duration (group I--13.2/SD 13.7 years, group II--8.2/SD 10.5 years), radiologically determined hernial size or preoperative severity of esophagitis. The regression of the severity of heartburn and regurgitation was prominent in both groups with no significant difference between the groups. Dysphagia before and after surgery was comparable in both groups. Esophagitis confirmed by EGDS remained in 3 of 16 cases in group I and in 9 of 164 cases in group II. The metaplastic changes in group I were followed every 6 months for 16-36 months (mean 28 months). In 13 cases the metaplastic segment demonstrated no changes, it became shorter in 3 cases. We didn't observe any complete regression of metaplasia. In the case with preoperative low grade dysplasia, the length of the segment did not change, we observed neither histological progression or regression.

CONCLUSIONS: Barrett's metaplasia had no influence on the regression of symptoms of GERD and esophagitis after antireflux surgery. No histological progression of Barrett's metaplasia has been observed after antireflux surgery. The EGDS follow-up should not be very frequent in cases of Barrett's esophagus without dysplasia and good postsurgical regression of symptoms.

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