Barretts's esophagus: does an antireflux procedure reduce the need for endoscopic surveillance?

Barrett's esophagus, a premalignant condition associated with chronic gastroesophageal reflux, carries an approximate 40-fold increase in the incidence of adenocarcinoma. Between 1975 and 1994, 113 patients with Barrett's esophagus underwent antireflux procedures at the Mayo Clinic. The antireflux procedure was performed more than 3 months after the diagnosis of Barrett's disease in 39 patients (34.5%) and during the initial preoperative evaluation in 74 (65.5%). Uncut Collis-Nissen fundoplication was performed in 69 patients (61.1%), Nissen fundoplication was performed in 16 (14.2%), cut Collis-Nissen fundoplication was performed in 12 (10.6%), Belsey repair was performed in nine (8.0%), Collis-Belsey repair was performed in six (5.3%), and Nissen fundoplication with an anterior gastropexy was performed in one (0.9%). There was one operative death (0.9% mortality). Morbidity occurred in 41 patients (36.3%), including cardiac arrhythmia in eight (7.0%), pneumonia in six (5.3%), empyema in five (4.4%), hemorrhage in four (3.6%), myocardial infarction in two (1.8%), and wound dehiscence, wound infection, perforated duodenal ulcer, and postoperative leak in one each (0.9%). Median follow-up for the 112 survivors of operation was 6.5 years (range 4 months to 18.2 years). Excellent or good alleviation of symptoms was obtained in 92 patients (82.2%). Ninety-nine patients (88.4%) are currently alive and 13 (11.6%) have died. Three patients (2.7%) subsequently had adenocarcinoma of the esophagus after the antireflux procedure at 13, 25, and 39 months; two of these died of cancer. The incidence of esophageal carcinoma in this select group of patients was one in 273.8 patient-years of follow-up. We conclude that although antireflux procedures in patients with Barrett's esophagus result in long-term control of reflux symptoms, the possibility of esophageal cancer still exists. Endoscopic surveillance should therefore be recommended.