Laparoscopic Nissen fundoplication in the treatment of Barrett's esophagus - 10 years of experience

Abstract

Introduction: Barrett's esophagus (BE) is a state in which the distal portion of esophageal mucosa becomes lined with cylindrical epithelium as a result of adaptive remodeling. It is widely accepted that the metaplastic lesions result from chronic irritation with gastric and/or duodenal contents in the course of reflux disease. For many years, research centered on the risk factors of BE and resulting adenocarcinoma. Anti-reflux operations are the only procedures which offer the possibility of treating the cause by restoring the anatomic barrier responsible for guarding against irritating effects of gastroduodenal content on the distal esophagus. Total (i.e. 360°) laparoscopic Nissen fundoplication (LNF) is considered the most effective amongst these procedures. Still, controversies related to the indications for anti-reflux surgery are frequently encountered.

Aim: Retrospective analysis of long-term treatment outcomes in patients with BE subjected to laparoscopic Nissen fundoplication.

Material and methods: The group included 42 BE patients, amongst them 30 men and 12 women. Initially, all the patients were treated conservatively for at least 1 year. The subgroup with dysplasia was subjected to preoperative argon plasma coagulation (APC). From 1 year after surgery (laparoscopic Nissen fundoplication), control biopsy specimens were obtained from the gastroesophageal junction of all the patients.

Results: None of the patients showed the development of esophageal adenocarcinoma during the follow-up period. Furthermore, no cases of dysplasia progression or de novo development of dysplasia were observed in the analyzed group. In the initial 12-24 months after surgery, complete regression of metaplasia was documented in 7 (31.8%) patients from group A, and a reduction in the area of Barrett's metaplasia was observed in another 7 patients (31.8%). Throughout the period of this study, persistent planoepithelial re-epithelialization was observed in 14 (70%) group B patients, i.e. in individuals with baseline dysplasia subjected to preoperative argon plasma ablation. In the remaining patients of this group, the developed changes of BE character were less advanced than at baseline.

Conclusions: Our opinion is that laparoscopic Nissen fundoplication, as a result of high effectiveness, represents the method of choice in the treatment of BE in the case of patients who were qualified for surgery.

Keywords: Barrett's esophagus; Nissen fundoplication; laparoscopy.

Photo 1

Barrett's metaplasia – the glandular epithelium, intestinalisation without dysplasia. Histochemical staining Alcian blue + PAS (pH 2.5) – acidic mucus tinged with blue, neutral red, pink, 20× lens (courtesy of Dr. K. Urbańczyk – Department of Pathology, Jagiellonian University Medical College)

Photo 2

Laparoscopic Nissen fundoplication – intraoperative view during preparation of the esophagus within the mediastinum