Reply to Kristo et al.

We thank you for your observations and comments about the role of surgical treatment for acid reflux in maintaining long-term disease remission after successful endoscopic therapy. We share your observations that although, in most patents, with combined endoscopic resection and radiofrequency ablation (RFA), we are able to clear the mucosal neoplasia and intestinal metaplasia that is Barrett’s esophagus, we do not reverse the persisting reflux insult that drives the biological transformation to Barrett’s esophagus and neoplasia.

The ongoing requirement for acid suppression after successful endoscopic treatment may well reduce the quantity of acid exposure to the distal esophagus but this has little impact on the number of reflux events overall [1]. Toxic compounds within the refluxate that can lead to persistent damage to squamous mucosa include duodenogastric contents such as bile, pepsin, and pancreatic proteolytic enzymes [2]. Furthermore, the mechanical clearance of refluxate after endotherapy might also be impaired as has been shown in patients with mucosal esophagitis when compared to those with endoscopy-negative reflux disease [3], a concept yet to be explored in the context of refractory Barrett’s esophagus.

Shaheen at al. [4] showed from data derived from the US registry that in patients undergoing endoscopic therapy for Barrett’s neoplasia prior antireflux surgery made no difference to the outcome. The authors examined 5537 patients undergoing RFA, of which 301 (5.4 %) had had a prior fundoplication. Complete eradication of intestinal metaplasia and dysplasia were achieved in 71 % and 87 %, respectively, of patients with a fundoplication, and 73 % and 87 %, respectively, of patients without a fundoplication (P = non-significant for both). Therefore the authors concluded that prior antireflux surgery made no difference to the outcome. However, there was little emphasis on the selection criteria for antireflux surgery or on the manometric and reflux characteristics that led to the surgical decision-making.

The role of surgery after successful endoscopic treatment has yet to be examined and may well find a place in carefully selected patients in whom significant reflux is more likely after successful therapy – for example those with a large hiatus hernia and significant exposure to acid (or exposure to weak acid/non-acids such as bile) despite maximum medical therapy.

• References

• 1 Fox M, Forgacs I. Gastro-oesophageal reflux disease. BMJ 2006; 332: 88-93
• 2 Pearson JP, Parikh S, Orlando RC et al. Review article: reflux and its consequences–the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP), Kingston-upon-Hull, UK, 21–23 April 2010. Aliment Pharmacol Ther 2011; 33: 1-71
• 3 Daum C, Sweis R, Kaufman E et al. Failure to respond to physiologic challenge characterizes esophageal motility in erosive gastro-esophageal reflux disease. Neurogastroenterol Motil 2011; 23: 517-e200
• 4 Shaheen NJ, Kim HP, Bulsiewicz WJ et al. Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U. S. RFA Registry. J Gastrointest Surg 2013; 17: 21-28; discussion 28-29