Barrett's Esophagus

Definition: normal lining of the esophagus is replaced by a type of lining normally found in the intestines (this is called intestinal metaplasia) as evidenced by the prescence of goblet cells.

- Occurs in ~10% of pts with GERD
- important to differentiate between short (<3cm) vs long (>3cm) Barrett's
- there is debate whether short segment Barretts is actually associated with a risk of metaplasia
- annual risk of adenoca in Barrett's is 0.8%/yr
- risk of metaplasia in long segment is high - 90%
- if high grade dysplasia found - risk of invasive focus is 50%

Pts with Barrett's Surgical Rx to manage reflux may be more important.
- medical therapy does not result in regression of Barrett's while there is some evidence that surgical therapy does result in regression of Barrett's
- Surgery may prevent the progression of metaplasia to dysplasia and subsequently cancer
- Medical therapy does not prevent alkaline reflux - whereas surgical therapy does and this may be a contributing factor to the presence of Barrett's

Workup of GERD

Preoperative W/U in patients with classic symptoms of GERD:
- EGD
- Manometry

Pts with more complex symptoms consider:
- EGD
- Manometry
- 24 hr pH monitor
- Barium swallow
- impedence study

Demeester scoring:
...

Surgical Management of GERD

Key Steps in Fundoplication:
1) Complete dissection of the esophageal hiatus and both crurae
2) Complete mobilization of the gastric fundus (+/- division of the short gastrics)
3) Closure of the hiatal defect
4) Creation of a tensionless wrap around a 50-60 Fr Bougie
5) Limiting the length of the wrap to 1.5-2.0 cm
6) Stabilizing the wrap to the esophagus with partial thickness bites of the esophagus while securing the wrap.

Complications of Fundo:
- 5-10% solid food dysphagia
- 2-3% have permenant dysphagia
- 7-10% have gas bloat, diarrhea, nausea, early satiety
- c/in 3-5 years some PTA are back on PPIs

Short Gastric Vessels:
- Study from Australia that demonstrates that there is no benefit to routinely taking the short gastrics

Variations to Fundoplication:
- Collis gastroplasty: used in setting of shortened esophagus.  Rarely indicated.  Be aware that 80% of pts are prone to esophagitis and pathologic esophageal acid exposure as a result.
- Toupet Fundoplication: 270-degree wrap where edges of fundus are secured to the lateral esophagus.  Used in the setting of pts with abnormal esophageal motility to prevent dysphagia and bloating.

Post-operative retching:
- patients are treated aggressively with anti-nauseants to prevent post-op N&V.  Should the pt have an espisode of N/V then a barium swallow should be performed to r/o wrap herniation or disruption.  If this is caught within 24-48 hrs then re-operation can be performed.  Otherwise 8-12 weeks should be allowed prior to any re-intervention.

Surgical Outcomes:
Spelcher, NEJM 1992: PPI vs open surgery (RCT, n~250)
- Open Nissen vs upto 4 meds for complicated GERD
- Both PPI and surgery effective in decreasing Sx and Esophagitis over 2 years - although surgery saw better improvements.
Spechler, JAMA 2001: Long-term results
- ~60% were back on PPI after 10yrs
- no difference was seen in rates of esophagitis in surgery and PPI groups.
- Pts should put this long term data into perspective when contemplating surgery.

Laparoscopic outcomes:
- >93% symptom free after 1 yr
- Transient dysphagia seen in 50% of pts - resolves within 3 weeks
- Long-term dysphagia seen ~10% of pts but well tolerated by most
- 3-4% require reoperation for unrelenting dysphagia or recurrent GERD
- Gas bloat avoided by floppy fundo



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