I read with great interest the article titled: “Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett’s Esophagus” recently published in the journal Gastroenterology. A cohort of almost 34000 patients with Barrett’s esophagus were followed for 32 years. Only 542 patients (1.6%) underwent Nissen fundoplication surgery. The remaining patients were treated with anti-reflux medications. 14 patients in the surgery group developed cancer. 437 patients in the medical group developed cancer. The authors concluded, using statistical analysis, that the risk of developing esophageal cancer did not decrease after anti-reflux surgery compared with antireflux medications. It was not only higher but cumulative: the risk increased over the years. Patients should therefore continue to be surveilled.
I agree with the surveillance recommendation for Barrett’s esophagus after Nissen fundoplication. However, should we conclude that Nissen fundoplication does not halt the metaplasia-dysplasia-adenocarcinoma sequence in patients with Barrett’s esophagus? Should we deny our patients with Barrett’s esophagus the most reliable procedure that stops both acid and bile reflux and put them on PPIs (no evidence for cancer prevention) for the rest of their lives? After all isn’t acid and bile reflux the most important risk factors for Barrett’s mucosa development and progression to cancer.
The reality is that not all Nissen fundoplications are created equal. A poorly performed Nissen fundoplication does not stop acid and bile reflux. A poorly performed Nissen fundoplication does not help anyone with Barrett’s esophagus. Similarly, a flawless Nissen fundoplication performed in the setting of severe longstanding GERD and long segment Barrett’s esophagus may be too late to prevent a focus of undetected low grade dysplasia from progressing to high grade dysplasia and cancer. The above study design does not control for these two very important variables. The authors rather assume that there should be no difference in length of Barrett’s segment between the two groups. If significantly more patients were offered surgery, one may accept such an assumption. However, less than 2% of the total study cohort had Nissen fundoplication surgery. In a clinical setting, patients with the most advanced disease tend to be offered surgery. Patients whose GERD has been progressing over many years and whose symptoms are no longer controlled by PPI therapy are more likely to undergo antireflux surgery. After all, inadequate symptom relief, is the most common indication for Nissen fundoplication. GERD symptom severity correlates with length of Barrett’s esophagus, likelihood of dysplasia and progression to cancer. Patients with more advanced Barrett’s esophagus are more likely to develop cancer especially after a poorly performed Nissen fundoplication. How many ineffective (poorly performed) Nissen fundoplications have been offered to patients in this study? Were these antireflux surgeries performed by expert hands?
Given the low number of Nissen fundoplication surgeries (542 over several years), it is safe to assume that the surgeons performing theses surgeries have limited expertise in anti-reflux surgery. Ineffective Nissen fundoplication exposes Barrett’s mucosa to progression to high grade dysplasia and adenocarcinoma. We all agree on this.
To summarize, not all Nissen fundoplication procedures are created equal. Patient selection and surgeon expertise play a huge part in determining the quality of Nissen fundoplication surgery. Unfortunately, this is not always taken into consideration in published studies leading to selection bias, and misleading results. This study was published in the journal Gastroenterology. A foregut surgeon and gastroenterologist commented on this study in the journal editorial. “These data argue strongly against antireflux surgery having any preventative benefit for the development of esophageal adenocarcinoma in patients with Barrett’s, so that outcome should not be used as a selling argument for antireflux surgery”. This a hardly the case at Houston Heartburn and Reflux Center. Our Nissen fundoplications result in high, short term and long-term success rate. Our patients are properly selected and worked up prior to surgery. We offer a solid post Nissen fundoplication surveillance program for Barrett’s esophagus. For all these reasons, we continue to recommend Nissen fundoplication, a properly performed Nissen fundoplication, as the most reliable treatment for GERD and the best cancer prevention option for Barrett’s esophagus. https://houstonheartburn.com/long-term-effect-of-nissen-fundoplication-on-barretts-esophagus.