Transcript No Slide Title

Laparoscopic Fundoplication and Barrett’s
Carlos A. Pellegrini
University of Washington
Seattle, WA
Innovare Conservando
Conservare: la base
The “Basics”
To understand when and how to
proceed with an operation in Barrett,s
Barrett’s: Progression to cancer
The Seattle Barrett’s Esophagus Project 1983-1998
N
Person/Years
N=ca
Inc
RR
<3cm
83
280
7
2.5
1
3-6cm
108
366
11
2.8
0.8
7-10cm
82
377
12
3.2
1
>10cm
36
142
10
7
1.2
309
1184
40
3.4
All
Rudolph et al, Ann Int Med 2000;132:612
No HGD on baseline biopsy
The Seattle Barrett’s Esophagus Project 1983-1998
N
Person/Years N=ca Inc RR
<3cm
69
256
1
0.4
1.0
3-6cm
84
342
2
0.6
1.5
7-10cm
62
337
3
0.9
1.8
>10cm
20
109
2
1.8 3.72
All
235
1045
8
0.8
Rudolph et al, Ann Int Med 2000;132:612
HGD on baseline biopsy
The Seattle Barrett’s Esophagus Project 1983-1998
N
<3cm
Person/Yea N=ca Inc
rs
14
23
6
26
3-6cm
24
43
9
21
0.8
7-10cm
20
40
9
23
0.8
>10cm
16
33
8
24
0.9
All
74
140
32
23
Rudolph et al, Ann Int Med 2000;132:612
RR
1
Natural history of Barrett’s
Sequence
GERD
-PROGRESSION
-ORDERLY
-TIMELY
Barrett’s
LG Dysplasia
25%
HG Dysplasia
Cancer
Fundoplication in 791 pts
N=145
N=646
Barrett's
No Barrett's
Barrett’s in 18% of patients
University of Washington Swallowing Center
Goals of therapy
• Treating symptoms
• Eliminating Barrett’s
• Decreasing risk of cancer
Barrett’s
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)
Outcomes of Lap Fundoplication
In patients without HGD
No dysplasia
• Operation
–
–
–
–
A difficult dissection can be anticipated
Short esophagus
Periesophagitis
Thickened tissues
Barrett’s
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
Study Design
Prospective Database
4,507 Patients with Esophageal Diseases
Initial symptom, functional, endoscopic, and radiologic evaluation
106 Barrett’s Patients
1994-2000 had LARS
2001-2002
All patients contacted for full evaluation
Mean 43 months f/u (Median 40 mo; 12-95mo)
Clinical
Endoscopic surveillance
pH/Manometry
106 Patients (100%)
90 patients (85%)
53 Patients (50%)
Effects of LARS on symptoms
Heartburn
(98 pts.)
100
90
80
70
60
% pts 50
40
30
20
10
0
96%
Absent
Improved
Same
Effects of LARS on symptoms
Regurgitation
(69 pts.)
100
90
80
70
60
% pts 50
40
30
20
10
0
84%
Absent
Improved
Same
Effects of LARS on symptoms
100
90
Dysphagia
(33 pts.)
80
70
60
% pts 50
82%
40
30
20
10
0
Absent
Improved
New Dysphagia – 10 patients
Mild (< 1 episode/week) in 8/10
Same
24-h pH monitoring
% time pH <4
50
45
40
35
30
Mean %
25
time pH<4
20
15
10
5
0
Pre-op
Post-op
Normal values
*
*
Distal esophagus
Proximal esophagus
* p < .001
Fate of the Barrett’s Epithelium
In all 90 patients with pre and post op bxs
33%
Pre-op
Post-op
No Intestinal Metaplasia
0
26 + 3 + 1
Metaplasia without dysplasia
75
48 + 4
Indefinite for Dysplasia
12
4
Low-grade Dysplasia
3
1
High-grade Dysplasia
0
1
Adenocarcinoma
0
1
+ 1
Fate of the Barrett’s Epithelium
In 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%
Efficacy of Medical and Surgical Therapy
to prevent Barrett’s metaplasia
Wetscher GJ et al., Ann Surg 2001;234:627
• 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
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
Barrett’s
Practical Issues
• When seeing a pt suspected of having Barrett’s
– Endoscopy and biopsy to confirm dx
• no dysplasia
• dysplasia (suspicion, certain, HGD, etc)
No HGD on baseline biopsy
The Seattle Barrett’s Esophagus Project 1983-1998
N
Person/Years N=ca Inc RR
<3cm
69
256
1
0.4
1.0
3-6cm
84
342
2
0.6
1.5
7-10cm
62
337
3
0.9
1.8
>10cm
20
109
2
1.8 3.72
All
235
1045
8
0.8
Rudolph et al, Ann Int Med 2000;132:612
HGD on baseline biopsy
The Seattle Barrett’s Esophagus Project 1983-1998
N
<3cm
Person/Yea N=ca Inc
rs
14
23
6
26
3-6cm
24
43
9
21
0.8
7-10cm
20
40
9
23
0.8
>10cm
16
33
8
24
0.9
All
74
140
32
23
Rudolph et al, Ann Int Med 2000;132:612
RR
1
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 sideeffects?
– 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
Esophageal Cancer
Videoendoscopic approaches
•
•
•
•
Small entry ports
No need to retract on wounds
Better exposure
Less manipulation
Easier Recovery
Decreased morbidity and mortality
Demographics
• 38 patients enrolled in Barrett’s surveillance
underwent esophagectomy
• 36 were contacted (95%) and 2 refused
• 34 participants total
– 84% male
– Average age:61 years (range 35-80)
Pathology Results
• Final pathologic examination revealed the following:
– 1 patient had low-grade dysplasia (received neoadjuvant chemotherapy
for a clinical T1N1M0, biopsy-proven adenocarcinoma)
– 14 patients had high-grade dysplasia
– 9 patients had carcinoma in situ
– 7 patients had Stage I disease
– 2 patients had Stage IIA disease
– 1 patient had Stage IIB disease
• Occult adenocarcinoma was found in one patient who was
thought preoperative to only have high-grade dysplasia (3%)
Survival
• Mean postop follow-up was 46
months (range 13-108)
• Thirty (88%) patients alive
• Four patients have died
– 3 from conditions unrelated to
esophageal cancer (tongue cancer,
coronary artery disease, renal
failure) and one from unknown
cause
• One patient developed
metastatic esophageal
carcinoma to the pleura and was
still alive at 28 months
postoperatively
Postoperative Quality of Life
100
90
80
70
60
50
40
30
20
10
0
PF
RP
BP
Study group
GH
VT
SF
RE
Norm s US population
Study group compared to National 1998 average SF 36v2 survey results.
PF= Physical functioning, RP= Role physical, BP= bodily pain, GH= General health, VT=
vitality, SF= Social functioning, RE= role emotional
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