Are there any medical or surgical interventions that cause regression of BO?

From Cancer Guidelines Wiki

Are there any medical or surgical interventions that cause regression of BO?

Introduction

Regression of Barrett's Oesophagus is defined by a reduction in the length or area of metaplastic columnar epithelium. The significance of partial or complete regression in Barrett’s Oesophagus is unclear. There are insufficient data to indicate that regression of the Barrett’s segment leads to a reduced incidence of adenocarcinoma. Available evidence is limited by a lack of randomised trials, variations in the definition of Barrett’s regression and differences in the method and duration of intervention. The degree of Barrett’s regression appears to be largest amongst case series of patients undergoing anti-reflux surgery although a randomised trial comparing surgical and medical therapy found the differences to be insignificant.

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Medical therapies

Combined analysis of randomised trials has not demonstrated a regression of Barrett’s Oesophagus with medical therapy.[1] Several studies including a case series of 188 patients treated with a proton-pump inhibitor over a mean follow-up of 5.1 years have reported an increase in the development of squamous islands within the Barrett’s segment although the significance of this finding is uncertain.[2]

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Surgical therapies

Although medical therapies reduce oesophageal acid exposure, gastro-oesophageal reflux of bile and other noxious agents may continue to occur. Anti-reflux surgery has therefore been proposed as a more effective treatment than medical therapy. Studies are largely in the form of case series and different surgical approaches have been described, reporting the incidence of regression at between 0-73%. Only one trial has compared surgery (Nissen fundoplication) with medical therapy in a randomised fashion.[3] The surgically treated group had a small but statistically significant reduction in the median length of the Barrett’s segment at a median follow-up of five years (5cm versus 4cm) and the medical group had a significant increase in the median length (4cm versus 5cm) although no difference in the rate of progression to high grade dysplasia or adenocarcinoma was found between the two groups.

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Evidence summary and recommendations

Evidence summary Level References
There are no medical therapies that result in clinically significant regression of Barrett’s Oesophagus. I [1]
Anti-reflux surgery may induce regression of Barrett’s Oesophagus although this is not associated with a decreased risk of high-grade dysplasia or adenocarcinoma. II [3]
Evidence-based recommendationQuestion mark transparent.png Grade
There is insufficient evidence to recommend the use of acid suppressive therapy for the regression of Barrett’s Oesophagus.
B
Evidence-based recommendationQuestion mark transparent.png Grade
Insufficient evidence exists to routinely recommend anti-reflux surgery for the regression of Barrett’s Oesophagus.
C


Practice pointQuestion mark transparent.png

Acid suppressive therapy and anti-reflux surgery can be used to control symptoms and heal reflux oesophagitis in patients with Barrett’s Oesophagus. There is insufficient evidence to recommend high dose (twice daily) acid suppressive therapy when symptom control or mucosal healing is achieved with standard dosing.

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References

  1. 1.0 1.1 Rees JR, Lao-Sirieix P, Wong A, Fitzgerald RC. Treatment for Barrett's oesophagus. Cochrane Database Syst Rev 2010 Jan 20;(1):CD004060 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20091557.
  2. Cooper BT, Chapman W, Neumann CS, Gearty JC. Continuous treatment of Barrett's oesophagus patients with proton pump inhibitors up to 13 years: observations on regression and cancer incidence. Aliment Pharmacol Ther 2006 Mar 15;23(6):727-33 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16556174.
  3. 3.0 3.1 Parrilla P, Martínez de Haro LF, Ortiz A, Munitiz V, Molina J, Bermejo J, et al. Long-term results of a randomized prospective study comparing medical and surgical treatment of Barrett's esophagus. Ann Surg 2003 Mar;237(3):291-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12616111.

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Appendices


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