Long-term (18 Years) Results of Patients With Long-segment Barrett Esophagus Submitted to Acid Suppression-duodenal Diversion Operation

Abstract

Objective: To determine late results of AS-DD procedure in long-segment (LSBE) and extralong-segment BE (ELSBE) using subjective and objective measurements to ascertain the histological impact over intestinal metaplasia (IM) and progression to EAC. Summary of Background Data: Barrett esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC), and Nissen fundoplication has proven to be unable to stop mixed reflux among them. Our group proposed a surgical procedure that handles pathophysiological changes responsible for BE. Methods: This prospective study included 127 LSBE and ELSBE subjects submitted to clinical and functional analyses. They were presented to selective vagotomy, fundoplication, partial gastrectomy with Roux-en-Y reconstruction. The changes in IM were determined in both groups. Results: Follow-up was completed at a mean of 18 years in 81% of the cases. Visick I-II scores were seen in 88% of LSBE and 65% in ELSBE (P < 0.01). There was significant healing of erosive esophagitis and esophageal peptic ulcers, and strictures were resolved in 71%. There was 38% of IM regression in LSBE. Two cases in each group progressed to EAC at a mean of 15 years. Pathologic acid reflux was abolished in 91% and duodenal in 100%. There was a regression of low-grade dysplasia to IM in 80%. Conclusions: AS-DD permanently eliminates pathologic refluxate to the esophagus. The progression to HGD/EAC is lower compared to medical treatment, with an 8-fold reduction in LSBE and 2.2-fold in ELSBE. AS-DD seems to influence IM behaviors, and it is a tool that could reduce and delay progression to EAC.

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

“…Therefore, we performed the fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy in LSBE patients to avoid acid and bile reflux, called acid suppression, and obtain an early and safe eradication with diversion procedure, known as acid suppression-duodenal diversion (AS-DD). With this procedure, regression of IM to cardiac mucosa was observed in 38% and LGD to IM in 80% of cases, at very long followup 14,17,35 . Despite these excellent results, we propose to add ablation in patients with LSBE C5M5 (Prague classification 3 ) or more to obtain early and permanent elimination of IM or LGD, considering the risk of progression at an incidence rate, for any dysplasia, of 1.4 cases/100 person-years and HGD/EAC of 0.9/100 person-years 31,39 .…”

“…However, laparoscopic fundoplication in LSBE patients fails to create an effective and permanent antireflux barrier, in almost 30% of cases 6 , 14 . Fundoplication combined with highly selective vagotomy is associated with high rate of recurrence of Barrett's esophagus (BE) and its complications 17 .…”