Laparoscopic Fundoplication and Barrett’s

Carlos A. PellegriniUniversity of Washington

Seattle, WA

GI Cancer CourseSaint Louis University

Topics to be covered

• Indications• Outcomes• Pt Selection• Choice of Procedure• Advantages

What is Barrett’s

• A definition that has evolved– Esophagus lined with columnar epithelium– same plus “greater than 3 cm”– same plus “only intestinal metaplasia”– Consensus conference 1998:

• Any portion of the esophagus lined by intestinal metaplasia proven by biopsy

Indications

• Barrett’s is related to GERD• Barrett’s may evolve into cancer• Doing a Laparoscopic Fundoplication MAY

– Cure symptoms of GERD– Decrease chances of evolving into cancer

Esophageal Acid ExposureEsophageal Acid Exposure

0 5 10 15 20 25 30

% Time pH <4

Barrett'sStrictureEsophagitisReflux SxNormals

Zaninotto, Ann Thorac Surg, 1989

% patients

Barrett’s epithelium:Epidemiology

• Found int 10-15% of pts undergoing endoscopy for symptoms of GERD.

• Prevalence in Olmstead Co: 23/100,000 pts in endoscopy and 376/100,000 in autopsy

• Short segment identified in 18% of 142 patients who had endoscopy at Beth Israel Hospital.

Fundoplication in 791 pts

Barrett'sNo Barrett's

N=646N=145

University of Washington Swallowing Center

Barrett’s in 18% of patients

Barrett’s epithelium and cancer

• Cancer develops in 0.2 to 2.1% (1%) per year in patients with Barrett’s.

• This is 30-125 times more common than in the regular population.

The Seattle Barrett’s Esophagus Project 1983-1998

NPerson/YearsN=caIncRR<3cm8328072.513-6cm108366112.80.87-10cm82377123.21>10cm361421071.2All3091184403.4

Rudolph et al, Ann Int Med 2000;132:612

Barrett’s: Progression to cancer

The Seattle Barrett’s Esophagus Project 1983-1998

NPerson/YearsN=caIncRR<3cm6925610.41.03-6cm8434220.61.57-10cm6233730.91.8>10cm2010921.83.72All235104580.8

Rudolph et al, Ann Int Med 2000;132:612

No HGD on baseline biopsy

The Seattle Barrett’s Esophagus Project 1983-1998NPerson/YearsN=caIncRR<3cm142362613-6cm24439210.87-10cm20409230.8>10cm16338240.9All741403223

Rudolph et al, Ann Int Med 2000;132:612

HGD on baseline biopsy

Natural history of Barrett’s

GERD

Barrett’s

LG Dysplasia

Cancer

HG Dysplasia

25%

Sequence-PROGRESSION

-ORDERLY-TIMELY

Goals of therapy

• Treating symptoms

• Eliminating Barrett’s

• Decreasing risk of cancer

Patient Selection & Choice of Procedure

• When seeing a pt suspected of having Barrett’s– Endoscopy and biopsy to confirm dx

• no dysplasia

• dysplasia (suspicion, certain, HGD, etc)

Barrett’s

Outcomes of Lap Fundoplication

In patients without HGD

No dysplasia

• Operation– A difficult dissection can be anticipated– Short esophagus– Periesophagitis– Thickened tissues

Does operation prevent cancer?

• 85 pts--> Antireflux op-->f/u median 5 yrs– Symptoms: absent 79%; recurrent 21%– 24 h pH monitoring: Normal 16/21 (76%)– Recurrent Hiatal hernia 16/79 (20%)– LGD --> No dysplasia 7/16 (44%)– IM --> Cardiac Mucosa 9/63 (14%)– No pt developed HGD of Cancer (401 pt/yrs)

• W. Hofstetter et al, Ann Surg; 2001

Barrett’s

Does operation prevent cancer?

• 103 pts--> Antireflux op-->f/u median 4.6 yrs– Short segment Barrett’s in 32%; LGD 4%– 8 pts have undergone re-operation– 66 pts returned for surveillance protocol

• 28 pts had NO Barrett’s, 35 had IM– No pt developed HGD of Cancer (337 pt/yrs)

• S. Bowers et al; J Gastrointest Surg 2001

Barrett’s

Study DesignProspective Database

4,507 Patients with Esophageal Diseases Initial symptom, functional, endoscopic, and radiologic evaluation

106 Barrett’s Patients 1994-2000 had LARS

2001-2002All patients contacted for full evaluation

Mean 43 months f/u (Median 40 mo; 12-95mo)

Endoscopic surveillance90 patients (85%)

Clinical106 Patients (100%)

pH/Manometry53 Patients (50%)

Effects of LARS on symptomsHeartburn

(98 pts.)

0102030405060708090

100

Absent Improved Same

% pts96%

Effects of LARS on symptomsRegurgitation

(69 pts.)

0102030405060708090

100

Absent Improved Same

% pts 84%

Effects of LARS on symptomsDysphagia(33 pts.)

0102030405060708090

100

Absent Improved Same

% pts 82%

New Dysphagia – 10 patients Mild (< 1 episode/week) in 8/10

24-h pH monitoring% time pH <4

05

101520253035404550

Distal esophagus Proximal esophagus

Mean % time pH<4

Pre-op

Post-opNormal values

**

* p < .001

Fate of the Barrett’s EpitheliumIn all 90 patients with pre and post op bxs

Pre-op Post-op

No Intestinal Metaplasia 0 26 + 3 + 1

Metaplasia without dysplasia 75 48 + 4

Indefinite for Dysplasia 12 4 + 1

Low-grade Dysplasia 3 1

High-grade Dysplasia 0 1

Adenocarcinoma 0 1

33%

Fate of the Barrett’s EpitheliumIn 54 patients with Short Segment Barrett’s

Pre-op Post-op

No Intestinal Metaplasia 0 26 + 3 + 1

No Dysplasia 46 20 + 2

Indefinite for Dysplasia 7 1

Low-grade Dysplasia 1 1

High-grade Dysplasia 0 0

Adenocarcinoma 0 0

55%

• Prospective study• 83 pts with reflux and mild esophagitis all

responders treated with PPIs for 2 years– Barrett’s developed in 12 (14.5%)

• 42 pts who had antireflux op– None developed Barrett’s

Efficacy of Medical and Surgical Therapy to prevent Barrett’s metaplasiaWetscher GJ et al., Ann Surg 2001;234:627

GERD, Barrett’s & Surgery

• Swedish population based study– 35274 men and 31691 women c GERD – 6406 men and 4671 women post surgery– Standarized Incidence ratio used Swedish

population as reference– First year of f/u excluded– Non op men: SIR 6.3 op pts SIR 14.1– Risk increased with time

Ye W et al Gastroenterology, 2001;121:1286

Practical Issues

• When seeing a pt suspected of having Barrett’s– Endoscopy and biopsy to confirm dx

• no dysplasia

• dysplasia (suspicion, certain, HGD, etc)

Barrett’s

The Seattle Barrett’s Esophagus Project 1983-1998

NPerson/YearsN=caIncRR<3cm6925610.41.03-6cm8434220.61.57-10cm6233730.91.8>10cm2010921.83.72All235104580.8

Rudolph et al, Ann Int Med 2000;132:612

No HGD on baseline biopsy

The Seattle Barrett’s Esophagus Project 1983-1998

NPerson/YearsN=caIncRR<3cm142362613-6cm24439210.87-10cm20409230.8>10cm16338240.9All741403223

Rudolph et al, Ann Int Med 2000;132:612

HGD on baseline biopsy

High grade dysplasia

• Definitive management to consider– Lesion

• Length, abnormalities, overall surface• additional information if available (DNA, etc)

– Patient• Age• Fitness• Ability/willingness to deal with risks/surveillance

Esophagectomy

• Choice of procedure• Transhiatal vs Transthoracic approach

– Transhiatal for most patients• Vagus sparing operation to minimize side-

effects?– Pros and cons

Advantages of THE

• Faster operation• A near-total esophagectomy is accomplished• Less risk of pulmonary complications

– No need to collapse lung, limited to mediastinum• Leaks are easier to treat• Less incidence of postoperative reflux

Disadvantages of THE• Less adequate lymphadenectomy• May compromise lateral margin• Intraoperative complications in “blind” spots

– Bleeding, tracheal laceration• Probably not ideal for mid-esophageal tumors• Difficult to teach

Videoendoscopic approaches• Small entry ports• No need to retract on wounds• Better exposure• Less manipulation

Easier Recovery Decreased morbidity and mortality

Esophageal Cancer

Conclusions• Barrett’s is an expression of advanced GER• Barrett’s pts have high incidence of complications

and may develop cancer• Antireflux procedures cure symptoms and may

reduce the chance of cancer in pts with no dysplasia• Liberal indication for antireflux surgery is

therefore warranted in patients with Barrett’s who have no dysplasia

Conclusion

• Patients with high grade dysplasia who enter a careful “watch and see” program can safely be observed

• 20-45% will develop cancer within 5 years• They will be discovered at a time when

esophagectomy can cure the disease