Is there any beneficial effect to be expected from highly selective vagotomy in addition to antireflux surgery?
A.N. Kingsnorth (Liverpool)
Although proton pump inhibitors have been found to reduce the length of Barrett's metaplasia with squamous re-epithelialization in some patient's, partial regression cannot be regarded as an adequate end point because the malignant risk still persists . Any studies considering either the effects of antireflux surgery or medication on the length of Barrett's mucosa must include long-term follow-up of patients preferably for a period of at least five years. Using this criterion, five years after surgery up to one quarter of patient's having had a Nissen fundoplication will show some reduction in the length of columnar metaplasia . A recent study has indicated that combining the benefits of an antireflux operation with an acid lowering procedure i.e. highly selective vagotomy, increases the likelihood of partial or complete regression of Barrett's mucosa . Fifty six patient's of medium age 48.5 years underwent antireflux surgery between 1983-1991. All patient's had metaplastic mucosa of at least 3 centimeters in length and preoperative manometry and pH studies were carried out preoperatively and postoperatively. Lower esophageal sphincter pressure increased from 8 millimeters of mercury to 17 millimeters of mercury after antireflux surgery. Partial or complete regression occurred in 24 patient's with a reduction in length from 8 centimeters (range 3-18 centimeters) to 4 centimeters (range 0-10 centimeters) and regression was complete in 5 patients. There was an increased likelihood of regression to occur with previous or concomitant highly selective vagotomy (and a better symptomatic response). However this study also showed that there was no change in metaplasia in 23 patient's, dysplasia developed in 2 patient's and carcinoma in 1 patient. It is concluded that highly selective vagotomy may be a useful adjunct to antireflux surgery in patient's who have symptomatic dyspepsia.
2. Ortiz A, Martinez de Haro LF, Parrilla P, Morales G, Molina J, Benuejo T, Liron P, Aguilar J. Conservative treatment versus antireflux surgery in Barrett's esophagus: long-term results of a prospective study; Br J Surg 1996;83:274-278.