The effects of antireflux surgery on esophageal function, cellular proliferation and apoptosis for Barrett's esophagus

Objective. To investigate the functional changes, cellular proliferation, and apoptosis alterations in Barrett's esophagus before and after Collis-Nissen operation (Esophageal elongation gastroplasty plus total fundoplication). Hypothesis. The Collis-Nissen gastroplasty, by creating a tension free fundoplication, provides good reflux control with durable and reliable reflux symptom relief, restores the lower esophageal sphincter (LES) mechanism, decreases cellular proliferation and improves apoptosis. Hence the cancer risk in Barrett's esophagus patients might be reduced. Methods. The 45 patients with histological proven Barrett's esophagus who had a Collis-Nissen operation between January 1989 and December 1997 were selected for the study. Besides symptom assessment, functional evaluations were obtained with radiological observations, radionuclide emptying studies, manometry, 24-hour pH monitoring, and endoscopy with biopsies. These results were retrospectively compared to that of a matched group of 33 BE patients who underwent a standard Nissen fundoplication between 1976 and 1989. Conclusion. (1) The Collis-Nissen gastroplasty is superior to the standard Nissen fundoplication in providing durable symptom relief and reflux control in Barrett's esophagus patients; (2) The Collis-Nissen gastroplasty restores the LES gradient while it impairs the sphincter's relaxation function, leaving an already altered poor esophageal clearance capacity unchanged; (3) A successful Collis-Nissen gastroplasty does not always abolish acid exposure in patients with Barrett's esophagus; (4) The Barrett's metaplastic mucosa does not regress after a Collis-Nissen gastroplasty; (5) It is the metaplastic intestinal mucosa that is subject to malignant progression in Barrett's esophagus since it displays increased proliferation and inhibited apoptosis in the columnar lined esophagus; (6) Immediately after an antireflux operation Barrett's mucosa shows an increase in both proliferation and apoptosis, possibly in response to operative manipulations; (7) Over time the Collis-Nissen gastroplasty results in decreased proliferation and heightened levels of apoptosis. This suggests that a decrease of exposure to a damaging refluxate could reduce the risk of malignant transformation in Barrett's patients; (8) Persistent postoperative acid exposure in Barrett's esophagus favors proliferation, inhibits apoptosis, and seems to result in more dysplasia. (Abstract shortened by UMI.)...