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

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 Zaninotto, Ann Thorac Surg, 1989 % patients

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=646 N=145 University of Washington Swallowing Center Barrett’s in 18% of patients

8. GER and Barrett’s Duration of Symptoms as a risk factor Lieberman et al. AJG 1997:92:1293

9. 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.

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

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

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

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

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

15. 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) Barrett’s

16. Outcomes of Lap Fundoplication In patients without HGD

17. No dysplasia Operation –A difficult dissection can be anticipated –Short esophagus –Periesophagitis –Thickened tissues

18. 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

19. 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 Barrett’s

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

21. Effects of LARS on symptoms 96%

22. Effects of LARS on symptoms 84%

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

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

25. Fate of the Barrett’s Epithelium In all 90 patients with pre and post op bxs Pre-op Post-op No Intestinal Metaplasia026 + 3 + 1 Metaplasia without dysplasia7548 + 4 Indefinite for Dysplasia 124 + 1 Low-grade Dysplasia31 High-grade Dysplasia01 Adenocarcinoma01 33%

26. Fate of the Barrett’s Epithelium In 54 patients with Short Segment Barrett’s Pre-opPost-op No Intestinal Metaplasia026 + 3 + 1 No Dysplasia4620 + 2 Indefinite for Dysplasia 71 Low-grade Dysplasia11 High-grade Dysplasia00 Adenocarcinoma00 55%

27. 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 Efficacy of Medical and Surgical Therapy to prevent Barrett’s metaplasia Wetscher GJ et al., Ann Surg 2001;234:627

28. 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

29. Practical Issues When seeing a pt suspected of having Barrett’s –Endoscopy and biopsy to confirm dx no dysplasia dysplasia (suspicion, certain, HGD, etc) Barrett’s

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

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

32. 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

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

34. 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

35. 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

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

37. 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

38. 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