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Laparoscopic Fundoplication and Barrett’s

GI Cancer Course Saint Louis University . Laparoscopic Fundoplication and Barrett’s. Carlos A. Pellegrini University of Washington Seattle, WA. Topics to be covered . Indications Outcomes Pt Selection Choice of Procedure Advantages. What is Barrett’s. A definition that has evolved

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Laparoscopic Fundoplication and Barrett’s

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  1. GI Cancer Course Saint Louis University Laparoscopic Fundoplication and Barrett’s Carlos A. Pellegrini University of Washington Seattle, WA

  2. Topics to be covered • Indications • Outcomes • Pt Selection • Choice of Procedure • Advantages

  3. 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

  4. 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

  5. Esophageal Acid Exposure % patients Zaninotto, Ann Thorac Surg, 1989

  6. 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.

  7. Fundoplication in 791 pts N=145 N=646 Barrett’s in 18% of patients University of Washington Swallowing Center

  8. 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.

  9. Barrett’s: Progression to cancer The Seattle Barrett’s Esophagus Project 1983-1998 Rudolph et al, Ann Int Med 2000;132:612

  10. No HGD on baseline biopsy The Seattle Barrett’s Esophagus Project 1983-1998 Rudolph et al, Ann Int Med 2000;132:612

  11. HGD on baseline biopsy The Seattle Barrett’s Esophagus Project 1983-1998 Rudolph et al, Ann Int Med 2000;132:612

  12. Natural history of Barrett’s Sequence GERD -PROGRESSION -ORDERLY -TIMELY Barrett’s 25% LG Dysplasia HG Dysplasia Cancer

  13. Goals of therapy • Treating symptoms • Eliminating Barrett’s • Decreasing risk of cancer

  14. 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)

  15. Outcomes of Lap Fundoplication In patients without HGD

  16. No dysplasia • Operation • A difficult dissection can be anticipated • Short esophagus • Periesophagitis • Thickened tissues

  17. 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

  18. 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

  19. 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 106 Patients (100%) Endoscopic surveillance 90 patients (85%) pH/Manometry 53 Patients (50%)

  20. Effects of LARS on symptoms 96%

  21. Effects of LARS on symptoms 84%

  22. Effects of LARS on symptoms 82% New Dysphagia – 10 patients Mild (< 1 episode/week) in 8/10

  23. 24-h pH monitoring% time pH <4 Normal values * * * p < .001

  24. Fate of the Barrett’s EpitheliumIn 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 + 1 Low-grade Dysplasia 3 1 High-grade Dysplasia 0 1 Adenocarcinoma 0 1

  25. Fate of the Barrett’s EpitheliumIn 54 patients with Short Segment Barrett’s 55% 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

  26. Efficacy of Medical and Surgical Therapy to prevent Barrett’s metaplasiaWetscher 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

  27. 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

  28. 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)

  29. No HGD on baseline biopsy The Seattle Barrett’s Esophagus Project 1983-1998 Rudolph et al, Ann Int Med 2000;132:612

  30. HGD on baseline biopsy The Seattle Barrett’s Esophagus Project 1983-1998 Rudolph et al, Ann Int Med 2000;132:612

  31. 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

  32. Esophagectomy • Choice of procedure • Transhiatal vs Transthoracic approach • Transhiatal for most patients • Vagus sparing operation to minimize side-effects? • Pros and cons

  33. 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

  34. 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

  35. Videoendoscopic approaches Esophageal Cancer • Small entry ports • No need to retract on wounds • Better exposure • Less manipulation • Easier Recovery • Decreased morbidity and mortality

  36. 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

  37. 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

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