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Does Barrett's esophagus regress after surgery (or proton pump inhibitors)?
Dig Dis 2014; 32(1-2):156-63DD

Abstract

Barrett's esophagus, the condition in which metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus, is a complication of gastroesophageal reflux disease (GERD). Metaplasia is a potentially reversible condition, and partial regression of Barrett's metaplasia has been documented with effective medical or surgical therapy for GERD. The important issue for patient management is not whether antireflux treatment causes Barrett's esophagus to regress, but rather whether antireflux therapy prevents cancer in Barrett's esophagus. Proton pump inhibitors (PPIs) would be expected to prevent this cancer because they heal reflux esophagitis, reduce exposure to a potential carcinogen (acid), and might prevent acid-induced proliferation and cancer-promoting cytokine secretion by esophageal epithelial cells. Furthermore, observational studies have shown that PPI use is associated with a decreased incidence of neoplasia in Barrett's esophagus. In theory, successful antireflux surgery, which eliminates the reflux of both acid and bile, should be better for cancer prevention than medical therapy, which only decreases the reflux of acid. However, high-quality studies show no significant difference in cancer incidence between medically and surgically treated patients with GERD and Barrett's esophagus. Furthermore, for individual patients with nondysplastic Barrett's metaplasia, the cancer risk is so small and the number needed to treat for cancer prevention with surgery so large, that it does not matter whether or not surgery provides a tiny margin of extra protection against cancer beyond that provided by medical therapy. The cost and risks of the operation overwhelm any small, additional cancer protective benefit. Antireflux surgery is very effective at controlling the endoscopic signs and symptoms of GERD, but the operation should not be recommended to patients solely with the rationale that it protects against cancer better than medical therapy.

Authors+Show Affiliations

Department of Medicine, VA North Texas Healthcare System, and the University of Texas Southwestern Medical Center at Dallas, Dallas, Tex., USA.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

24603402

Citation

Spechler, Stuart Jon. "Does Barrett's Esophagus Regress After Surgery (or Proton Pump Inhibitors)?" Digestive Diseases (Basel, Switzerland), vol. 32, no. 1-2, 2014, pp. 156-63.
Spechler SJ. Does Barrett's esophagus regress after surgery (or proton pump inhibitors)? Dig Dis. 2014;32(1-2):156-63.
Spechler, S. J. (2014). Does Barrett's esophagus regress after surgery (or proton pump inhibitors)? Digestive Diseases (Basel, Switzerland), 32(1-2), pp. 156-63. doi:10.1159/000357184.
Spechler SJ. Does Barrett's Esophagus Regress After Surgery (or Proton Pump Inhibitors). Dig Dis. 2014;32(1-2):156-63. PubMed PMID: 24603402.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Does Barrett's esophagus regress after surgery (or proton pump inhibitors)? A1 - Spechler,Stuart Jon, Y1 - 2014/02/28/ PY - 2014/3/8/entrez PY - 2014/3/8/pubmed PY - 2014/11/10/medline SP - 156 EP - 63 JF - Digestive diseases (Basel, Switzerland) JO - Dig Dis VL - 32 IS - 1-2 N2 - Barrett's esophagus, the condition in which metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus, is a complication of gastroesophageal reflux disease (GERD). Metaplasia is a potentially reversible condition, and partial regression of Barrett's metaplasia has been documented with effective medical or surgical therapy for GERD. The important issue for patient management is not whether antireflux treatment causes Barrett's esophagus to regress, but rather whether antireflux therapy prevents cancer in Barrett's esophagus. Proton pump inhibitors (PPIs) would be expected to prevent this cancer because they heal reflux esophagitis, reduce exposure to a potential carcinogen (acid), and might prevent acid-induced proliferation and cancer-promoting cytokine secretion by esophageal epithelial cells. Furthermore, observational studies have shown that PPI use is associated with a decreased incidence of neoplasia in Barrett's esophagus. In theory, successful antireflux surgery, which eliminates the reflux of both acid and bile, should be better for cancer prevention than medical therapy, which only decreases the reflux of acid. However, high-quality studies show no significant difference in cancer incidence between medically and surgically treated patients with GERD and Barrett's esophagus. Furthermore, for individual patients with nondysplastic Barrett's metaplasia, the cancer risk is so small and the number needed to treat for cancer prevention with surgery so large, that it does not matter whether or not surgery provides a tiny margin of extra protection against cancer beyond that provided by medical therapy. The cost and risks of the operation overwhelm any small, additional cancer protective benefit. Antireflux surgery is very effective at controlling the endoscopic signs and symptoms of GERD, but the operation should not be recommended to patients solely with the rationale that it protects against cancer better than medical therapy. SN - 1421-9875 UR - https://www.unboundmedicine.com/medline/citation/24603402/Does_Barrett's_esophagus_regress_after_surgery__or_proton_pump_inhibitors_ L2 - https://www.karger.com?DOI=10.1159/000357184 DB - PRIME DP - Unbound Medicine ER -