Oelschlager Brant K, Barreca Marc, Chang Lilly, Oleynikov Dmitry, Pellegrini Carlos A
The Swallowing Center and Department of Surgery The University of Washington, Seatle, Washington 98195-6410, USA.
Ann Surg. 2003 Oct;238(4):458-64; discussion 464-6. doi: 10.1097/01.sla.0000090443.97693.c3.
Patients with Barrett's esophagus (BE) are frequently offered laparoscopic antireflux surgery (LARS) to treat symptoms. The effectiveness of this operation with regards to symptoms and to the evolution of the columnar-lined epithelium remains controversial.
We analyzed the course of 106 consecutive patients with BE who underwent LARS between 1994 and 2000, representing 14% of all LARS (754) performed in our institution during that period. All 106 patients agreed to clinical follow-up in 2002 at 40 months (median; range, 12-95 months). Fifty-three patients (50%) agreed to functional evaluation (manometry and 24-hour pH monitoring); 90 patients (85%) to thorough endoscopy, with appropriate biopsies and histologic evaluation to determine the status of BE.
Heartburn improved in 94 (96%) of 98 and resolved in 69 patients (70%) after LARS. Regurgitation improved in 58 (84%) of 69 and dysphagia improved in 27 (82%) of 33. Distal esophageal acid exposure improved in 48 (91%) of 53 patients tested and returned to normal in 39 patients (74%). One patient underwent reoperation 2 days after fundoplication (gastric perforation). Preoperatively, biopsy revealed BE without dysplasia in 91 patients, BE indefinite for dysplasia in 12 patients, and low-grade dysplasia in 3 patients. Fifty-four of the 90 patients with endoscopic follow-up had short-segment BE (<3cm), and 36 had long-segment BE (>3cm) preoperatively. Postoperatively, endoscopy and pathology revealed complete regression of intestinal metaplasia (absence of any sign suggestive of BE) in 30 (55%) of 54 patients with short-segment BE but in 0 of 36 of those with long-segment BE. Among patients with complete regression, 89% of those tested with pH monitoring had normal esophageal acid exposure. This was observed in 69% of those who failed to have complete regression. One patient developed adenocarcinoma within 10 months of LARS.
In patients with BE, LARS provides excellent control of symptoms and esophageal acid exposure. Moreover, intestinal metaplasia regressed in the majority of patients who had short-segment BE and normal pH monitoring following LARS, a fact that was, heretofore, not appreciated. LARS should be recommended to patients with BE to quell symptoms and to prevent the development of cancer.
巴雷特食管（BE）患者常接受腹腔镜抗反流手术（LARS）以缓解症状。该手术在缓解症状及柱状上皮化生演变方面的有效性仍存在争议。
我们分析了1994年至2000年间连续接受LARS的106例BE患者的病程，占同期我院实施的所有LARS（754例）的14%。所有106例患者均于2002年同意进行40个月（中位数；范围12 - 95个月）的临床随访。53例患者（50%）同意进行功能评估（测压和24小时pH监测）；90例患者（85%）同意接受全面内镜检查，并进行适当活检和组织学评估以确定BE的状态。
98例患者中94例（96%）烧心症状改善，69例（70%）症状消失。69例患者中58例（84%）反流症状改善，33例患者中27例（82%）吞咽困难症状改善。53例接受检测的患者中48例（91%）食管远端酸暴露改善，39例（74%）恢复正常。1例患者在胃底折叠术后2天接受再次手术（胃穿孔）。术前，活检显示91例患者为无发育异常的BE，12例患者为发育异常不明确的BE，3例患者为低度发育异常。90例接受内镜随访的患者中，54例术前为短节段BE（<3cm），36例为长节段BE（>3cm）。术后，内镜检查及病理显示，54例短节段BE患者中有30例（55%）肠化生完全消退（无任何提示BE的迹象），而36例长节段BE患者中无1例消退。在肠化生完全消退的患者中，89%接受pH监测的患者食管酸暴露正常。未完全消退的患者中这一比例为69%。1例患者在LARS术后10个月内发生腺癌。
对于BE患者，LARS能有效控制症状和食管酸暴露。此外，大多数短节段BE且LARS术后pH监测正常的患者肠化生消退，这一事实此前未被认识到。应向BE患者推荐LARS以缓解症状并预防癌症发生。
