Comparative study between laparoscopic Nissen fundoplication with and without endoscopic mucosal resection in the management of Barrett’s esophagus

Background
Barrett’s esophagus (BE) is a metaplastic lesion in the distal esophagus that results from chronic irritation with gastric contents in the course of reflux disease. The relative risk of developing esophageal adenocarcinoma in patients with BE appears to be 30-fold higher than normal individuals. Antireflux operations may offer the possibility of treating the cause by restoring the anatomic barrier responsible for guarding against irritating effects of gastroduodenal content on the distal esophagus. Laparoscopic floppy Nissen fundoplication (LNF) is considered the most effective among these procedures. Endoscopic mucosal resection (EMR) is now an established therapy for early eradication of BE and prevention of progression to dysplasia.
Aim
The purpose of this research was to evaluate the effect of adding EMR technique before LNF for the treatment of gastroesophageal reflux disease complicated by BE without dysplasia.
Patients and methods
A prospective randomized study was performed on 36 patients complaining of chronic reflux with endoscopic Barrett’s changes from July 2017 to July 2019, with a minimum of 18 months of follow-up at Ain Shams University Hospitals. In group A (18 patients), floppy LNF was done alone, and in group B (18 patients), floppy LNF was done preceded by EMR. Clinical outcomes were collected preoperatively and postoperatively, namely, the reflux symptoms, dysphagia score, and rate of regression/progression or recurrence of Barrett’s epithelium in each group.
Results
Symptomatic esophageal stricture that needed endoscopic dilation was noted during the 3-month follow-up in seven (38.8%) patients in group B, compared with one (5.5%) patient in group A (<0.001). Both interventions showed significant improvement of reflux symptoms during the whole follow-up period. Collectively at the end of the study, six (33.3%) patients had recurrence of Barrett’s mucosa in group A, and one (5.5%) patient failed to achieve complete regression of Barrett’s mucosa in group B (=0.035).
Conclusion
Although a higher rate of dysphagia was associated with EMR combined with LNF, EMR seems to be a safe modality, with a high rate of success in complete eradication of BE in symptomatic patients with gastroesophageal reflux disease when combined with floppy NF. This combined treatment had a decreased rate of recurrence of Barrett’s epithelium compared with LNF alone.