Endoscopic Ablation Combined With Fundoplication Plus Acid Suppression-Duodenal Diversion Procedure for Long Segment Barrett´s Esophagus: Early and Long-Term Outcome

Abstract

BACKGROUND: The addition of endoscopic ablative therapy plus proton pump inhibitors or fundoplication is postulated for the treatment of patients with long-segment Barrett´s esophagus (LSBE); however, it does not avoid acid and bile reflux in these patients. Fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy is proposed as an acid suppression-duodenal diversion procedure demonstrating excellent results at long-term follow-up. There are no reports on therapeutic strategy with this combination. AIMS: To determine the early and long-term results observed in LSBE patients with or without low-grade dysplasia who underwent the acid suppression-duodenal diversion procedure combined with endoscopic therapy. METHODS: Prospective study including patients with endoscopic LSBE using the Prague classification for circumferential and maximal lengths and confirmed by histological study. Patients were submitted to argon plasma coagulation (21) or radiofrequency ablation (31). After receiving treatment, they were monitored at early and late follow-up (5–12 years) with endoscopic and histologic evaluation. RESULTS: Few complications (ulcers or strictures) were observed after the procedure. Re-treatment was required in both groups of patients. The reduction in length of metaplastic epithelium was significantly better after radiofrequency ablation compared to argon plasma coagulation (10.95 vs 21.15 mms for circumferential length; and 30.96 vs 44.41 mms for maximal length). Intestinal metaplasia disappeared in a high percentage of patients, and histological long-term results were quite similar in both groups. CONCLUSIONS: Endoscopic procedures combined with fundoplication plus acid suppression with duodenal diversion technique to eliminate metaplastic epithelium of distal esophagus could be considered a good alternative option for LSBE treatment.

Development of Adenocarcinoma After Radiofrequency Ablation of Barrett’s Esophagus Associated to Fundoplication and Suppression-Duodenal Diversion Procedure: A Lesson to Be Learned

“…During the postoperative follow-up, eradication of dysplasia was obtained, as shown in Table 5 of this paper. However, in one patient initially presenting low grade dysplasia, after 5 years of follow-up, the presence of adenocarcinoma at distal esophagus was confirmed histologically, probably remaining buried cells ( Table 1 ) 1 . The complete assessment included computed tomography (CT) scan, positron emission tomography (PET) scan, and endo-sonography, affirming a T1b esophageal adenocarcinoma.…”

“…Walter de Biase SILVA-NETO 1 , Claudemiro QUIRESE 1 , Eduardo Guimarães Horneaux de MOURA 2 , Fabricio Ferreira COELHO 3 , Paulo HERMAN 3 ABSTRACT -Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up.…”

“…Recently, it was published the paper “Suppression-duodenal diversion procedure for long-segment Barrett´s esophagus: early and long-term outcome” 1 . During the postoperative follow-up, eradication of dysplasia was obtained, as shown in Table 5 of this paper.…”

“…Despite the fact that endoscopic eradication therapy is an effective and durable treatment for Barrett’s esophagus (BE) related neoplasia, even after achieving initial successful eradication, these patients remain at risk of recurrence and require continuous examinations. Failure of radiofrequency ablation (RFA) and argon plasma coagulation (APC) is reported in 10–20% of cases 1 , 3 .…”