Esophagus to Small Intestine

Gastroenterology. 2024;166(1):132–8.e3

Åkerström JH, Santoni G, von Euler Chelpin M, Ness-Jensen E, Kauppila JH, Holmberg D, Lagergren J

Antireflux surgery versus antireflux medication and risk of esophageal adenocarcinoma in patients with Barrett’s esophagus

Background and aims: Antireflux treatment is recommended to reduce esophageal adenocarcinoma (EAC) in patients with Barrett’s esophagus (BE). Antireflux surgery (fundoplication) counteracts gastroesophageal reflux of all types of carcinogenic gastric content and reduces esophageal acid exposure to a greater extent than antireflux medication (e.g., proton-pump inhibitors). The authors examined the hypothesis that antireflux surgery prevents EAC to a larger degree than antireflux medication in patients with BE.
Methods: This multinational and population-based cohort study included all patients with a diagnosis of BE in any of the national patient registries in Denmark (2012–2020), Finland (1987–1996 and 2010–2020), Norway (2008–2020), or Sweden (2006–2020). Patients who underwent antireflux surgery were compared with non-operated patients using antireflux medication. The risk of EAC was calculated using multivariable Cox regression, providing hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for age, sex, country, calendar year, and comorbidity.
Results: The cohort consisted of 33,939 patients with BE. Of these, 542 (1.6%) had undergone antireflux surgery. During up to 32 years of follow-up, the overall HR was not decreased in patients having undergone antireflux surgery compared with non-operated patients using antireflux medication, but rather increased (adjusted HR = 1.9; 95% CI: 1.1–3.5). In addition, HRs did not decrease with longer follow-up, but instead increased for each follow-up category, from 1.8 (95% CI: 0.6–5.0) within 1–4 years of follow-up to 4.4 (95% CI: 1.4–13.5) after 10–32 years of follow-up.

Conclusions: Patients with Barrett’s esophagus who undergo antireflux surgery do not seem to have a lower risk of esophageal adenocarcinoma than those using antireflux medication.

Prof. Dr. Dr. J. Lagergren, Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, E-Mail:

DOI: 10.1053/j.gastro.2023.08.050

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