Influence of Fundoplication on Remission and Recurrence of Intestinal Metaplasia after Ablation of Barrettʼs Esophagus

Abstract

Purpose: Radiofrequency ablation (RFA) is an effective treatment for Barrett's dysplasia in conjunction with adequate acid reflux control. Fundoplication is a treatment option for persistent gastroesophageal reflux in spite of optimal pharmacotherapy. Our aim was to assess the effect of fundoplication in achieving complete remission of intestinal metaplasia (CRIM) and recurrence after successful RFA. Methods: We performed a retrospective cohort analysis of patients who underwent RFA for Barrett's dysplasia at a tertiary referral center from Jan. 2003 to Jun. 2012. All patients were on proton pump inhibitors following RFA. CRIM was defined as the absence of intestinal metaplasia (IM) in 2 consecutive endoscopies with biopsies. Recurrence was defined as the reappearance of IM with any grade of dysplasia after CRIM. Demographic and endoscopic factors associated with CRIM or recurrences were assessed by univariate and multivariate analyses. The effect of pre-RFA fundoplication to either time to CRIM or recurrence was assessed by Kaplan-Meier survival estimates. Results: A total of 206 patients were included in the analysis. There were 28 (13.6%) patients who had pre-RFA fundoplication. Patients were followed for 26.69 ±18.91 months after their first RFA session. Baseline characteristics are summarized in Table 1 which showed no significant difference between those with and without fundoplication. There was no association of fundoplication with either achieving CRIM (HR 0.93, 95% CI: 0.47-1.65) or recurrence (HR 0.99, 0.15-3.81) after controlling for age, number of RFA sessions, length of Barrett's esophagus (BE) segment and hiatal hernia in a multivariate Cox proportional hazards analysis. Figure 1 presents the Kaplan-Meier plot of patients with and without fundoplication in relation to CRIM. Time intervals for both CRIM (p=0.87) and recurrence (p=0.90) were not different between the two groups based on Mantel-Cox statistics.Table: Baseline characteristics of subjects with and without pre-RFA fundoplicationFigure: [62]Conclusion: In our cohort of patients, fundoplication was not associated with either time to CRIM or recurrence. Future studies with long term follow-up data and evidence of sufficient acid control, measured by pH impedance after fundoplication are needed to assess the effect of surgical reflux control on BE eradication following RFA. Disclosure: Dr. Wang - Consultant and research support from: Covidien (Barrx); Ninepoint Medical; CDX Diagnostics; Fujinon; Pinnacle Biologics; Ms. Lutzke - Research support: Covidien (Barrx); Fujinon; Ninepoint; Dr. Prasad Iyer - Research support: Takeda.