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Barrett's Esophagus and Intestinal Metaplasia
Abstract & Commentary
By Helen Sohn, MD, Assistant Professor of Surgery, Department of Surgery, University of Southern California. Dr. Sohn reports no financial relationship relevant to this field of study.
Synopsis: Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.
Source: Csendes A, et al. Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg. 2006;10:259-264.
Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity were submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and 3 patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing 7 patients with short-segment Barrett's esophagus (BE) and 5 patients with long-segment BE. Body mass index (BMI) decreased significantly from 43.2 kg/m2 to 29.4 kg/m2 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients one year after surgery. Preoperative, erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in 4 patients (57%) with short-segment BE and in one patient (20%) with long-segment BE. Two (67%) of 3 cases with CIM had regression to cardiac mucosa.
There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent. (J Gastrointest Surg. 2006;10:259-264.)
When the stomach is resected to a 20 mL pouch, acid production reduces to a minimum so that no acid can reflux into the esophagus. Therefore, Roux-en-Y gastric bypass procedure is considered to be an anti-reflux procedure. This study reports the findings of endoscopic surveillance of intestinal metaplasia in morbidly obese patients after their "weight reducing/anti-reflux" gastric bypass surgery. There were 15 patients out of 557 who had evidence of intestinal metaplasia of either the esophagus or cardia who were followed for 24-29 months after surgery. They lost weight, reflux symptoms disappeared, erosions and ulcers were healed, no progression to dysplasia occurred, and about half showed regression of their intestinal metaplasia. And though not reported, their obesity-related comorbidities probably subsided also. In this study, in the patient population with morbid obesity and intestinal metaplasia, gastric bypass surgery was increasingly beneficial in that it helped them lose weight, and therefore, decrease comorbidities, treat reflux symptoms successfully, and treat the complications of reflux disease, such as erosions, ulcers, and intestinal metaplasia.
Csendes and colleagues do not mention whether there were any patients without intestinal metaplasia who had symptomatic reflux disease. There must have been since gastroesophageal reflux disease is more common than Barrett's esophagus, which is a complication of untreated reflux. It would have been nice to see if gastric bypass procedure also treated uncomplicated reflux symptoms such as heartburn. It should, theoretically, but they did not provide any data on that.
As with any patients with Barrett's esophagus, it is important to follow them with surveillance upper endoscopies to evaluate the progression or regression of intestinal metaplasia with some sort of treatment, may it be medical or surgical. Medical therapy reduces acidity, but not the amount of reflux, whereas surgical therapy reduces the reflux. Barrett's esophagus should be aggressively treated and followed because it can progress to cancer. It will be interesting to see updated information on long-term follow-up of these gastric bypass patients regarding the status of the intestinal metaplasia, whether they continue to regress, plateau, or if there are any cases of progression of the disease.