Reliability of reflux symptoms to detect recurrent gastrooesophageal reflux following fundoplication in patients with long segment Barrett's oesophagus

Background: Patients with long-segment Barrett's oesophagus (≥3cm) are at risk for developing adenocarcinoma. Recurrence of gastroesophageal reflux following fundoplication may increase that risk. Reflux without heartburn may prevail in these patients, but the prevalence of asymptomatic reflux after fundoplication is not known. It was the purpose of this study to shed light on the relationship of recurrent reflux and associated symptoms in patients with long-segment intestinal metaplasia who have undergone fundoplication.

Patients and methods: From the records of patients who have undergone laparoscopic fundoplication for symptomatic gastroesophageal reflux 30 cases were retrieved with a preoperative diagnosis of long-segment Barrett's oesophagus (oesophageal segment of intestinal metaplasia, containing goblet cells and extending over ≥3cm). Four patients had died, two of them from adenocarcinoma of the oesophagus, and one was lost to follow up. 25 patients could be contacted, and 21 consented to participate in the study. The examinations comprised upper GI endoscopy with biopsy, 24h pH-metry and a structured interview based upon the GLQI (Gastrointestinal quality of life index). Median age was 66 years (43–85), and the M/F ratio was 4.

Results: Six patients (29%) reported reflux symptoms (heartburn and/or regurgitation) at least two times per week and/or the need for proton pump inhibitors to control reflux symptoms. The interval between operation and reccurrence of reflux symptoms was 4 to 48 months (median: 19). The remaining 15 patients (71%) were symptom free after an interval of 7 to 148 (median: 98) months. Seven (47%) of the 15 patients without symptoms hat abnormal pH-metry measurements, as compared to all (100%) of the six symptomatic cases (Fisher's Exact Test: p=0.03).

Conclusion: A considerable, statistically significant proportion of patients with long segment Barrett's oesophagus who have undergone fundoplication exhibit recurrent reflux at pH-metry in spite of absent reflux symptoms. We contend that periodic surveillance in asymptomatic patients with long-segment Barrett's oesophagus and fundoplication might be appropriate because of the frequent occurrence of asymptomatic reflux recurrence.