The relief of symptoms remains the primary force driving antireflux surgery in patients with Barrett's esophagus. Healing of esophageal mucosal injury and the prevention of disease progression are important secondary goals. In this regard, patients with Barrett's esophagus are no different than the broader population of patients with GE reflux. Antireflux surgery should be considered when patient factors suggest severe disease or predict the need for long-term medical management, both of which are almost always true in patients with Barrett's esophagus.
PPI therapy, both to relieve symptoms and to control any coexistent esophagitis or stricture, is an acceptable treatment option in patients with Barrett's esophagus. Once initiated, however, most patients with Barrett's will require lifelong treatment. Complete control of reflux with PPI therapy can be difficult, however, as has been highlighted by studies of acid breakthrough while on therapy. Ablation trials have shown that mean doses of 56 mg of omeprazole are necessary to normalize 24-hour esophageal pH studies. Antireflux surgery likely results in more reproducible and reliable elimination of reflux of both acid and duodenal content, although long-term outcome studies suggest that as many as 25% of patients postfundoplication have persistent pathologic esophageal acid exposure confirmed by 24-hour pH studies.58
An important consideration is that patients with Barrett's esophagus generally have severe GERD, with its attendant sequelae such as large hiatal hernia, stricture, shortened esophagus, and poor motility. These anatomic and physiologic features make successful antireflux surgery a particular challenge in this population. Indeed, recent data suggest that antireflux surgery in patients with Barrett's esophagus may not be as successful in the long term as in those without Barrett's.
Studies focusing on the symptomatic outcome following antireflux surgery in patients with Barrett's esophagus document excellent to good results in 72% to 95% of patients at 5 years following surgery The outcome of laparoscopic Nissen fundoplication in patients with Barrett's esophagus has been assessed at 1 to 3 years after surgery.Reflux symptoms were absent postoperatively in 79% of the patients. Postoperative 24-hour pH was normal in 17 of 21 (81%) patients. Ninety-nine percent of the patients considered themselves cured or improved, and 97% were satisfied with the surgery.