The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review - PubMed (original) (raw)

Review

The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review

Eugene Y Chang et al. Ann Surg. 2007 Jul.

Abstract

Objective: To determine whether patients with Barrett esophagus who undergo antireflux surgery differ from medically treated patients in incidence of esophageal adenocarcinoma and probability of disease regression/progression.

Summary background data: Barrett esophagus is a risk factor for the development of esophageal adenocarcinoma. A question exists as to whether antireflux surgery reduces this risk.

Methods: Query of PubMed (1966 through October 2005) using predetermined search terms revealed 2011 abstracts, of which 100 full-text articles were reviewed. Twenty-five articles met selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled adults with biopsy-proven Barrett esophagus, specified treatment-type rendered, followed up patients with endoscopic biopsies no less than12 months of instituting therapy, and provided adequate extractable data. The incidence of adenocarcinoma and the proportion of patients developing progression or regression of Barrett esophagus and/or dysplasia were extracted.

Results: In surgical and medical groups, 700 and 996 patients were followed for a total of 2939 and 3711 patient-years, respectively. The incidence rate of esophageal adenocarcinoma was 2.8 (95% confidence interval, 1.2-5.3) per 1000 patient-years among surgically treated patients and 6.3 (3.6-10.1) among medically treated patients (P = 0.034). Heterogeneity in incidence rates in surgically treated patients was observed between controlled studies and case series (P = 0.014). Among controlled studies, incidence rates were 4.8 (1.7-11.1) and 6.5 (2.6-13.8) per 1000 patient-years in surgical and medical patients, respectively (P = 0.320). Probability of progression was 2.9% (1.2-5.5) in surgical patients and 6.8% (2.6-12.1) in medical patients (P = 0.054). Probability of regression was 15.4% (6.1-31.4) in surgical patients and 1.9% (0.4-7.3) in medical patients (P = 0.004).

Conclusions: Antireflux surgery is associated with regression of Barrett esophagus and/or dysplasia. However, evidence suggesting that surgery reduces the incidence of adenocarcinoma is largely driven by uncontrolled studies.

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Figures

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FIGURE 1. Search strategies used in systematic review and numbers of studies included at each stage.

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FIGURE 2. Cumulative pooled estimates of incidence of adenocarcinoma (A) for medically treated patients and (B) for surgically treated patients. Each successive row shows the cancer incidence rate and 95% confidence interval when data are pooled from that study and all studies preceding it in chronological order.

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FIGURE 3. Comparison of pooled incidence rates of esophageal adenocarcinoma between surgically and medically treated patients. This comparison was repeated using only controlled studies and again using only case series. To test for heterogeneity, cancer incidence rates among each treatment group were also compared between case series and controlled studies.

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FIGURE 4. Proportions of patients with progression or regression of dysplasia and regression to squamous epithelium.

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FIGURE 5. Proportions of patients progressing from each grade of dysplasia to esophageal adenocarcinoma.

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FIGURE 6. Comparison of probability of regression to lower grades of dysplasia, nondysplastic, or nonmetaplastic tissue, between surgically and medically treated patients. This comparison was repeated using only controlled studies and again using only case series. To test for heterogeneity, probability of regression was also compared between case series and controlled studies within each treatment group.

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FIGURE 7. Comparison of probability of progression to more advanced grades of dysplasia, between surgically and medically treated patients. This comparison was repeated using only controlled studies and again using only case series. To test for heterogeneity, probability of progression was also compared between case series and controlled studies, within each treatment group.

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