Laparoscopic total fundoplication is superior to medical treatment for reducing the cancer risk in Barrett's esophagus: a long-term analysis.

The present study aims to compare the effectiveness of surgical and medical therapy in reducing the risk of cancer in Barrett's esophagus in a long-term evaluation. A prospective cohort was designed that compared Barrett's esophagus patients submitted to medical treatment with omeprazole or laparoscopic Nissen fundoplication. The groups were compared using propensity score matching paired by Barrett's esophagus length. A total of 398 patients met inclusion criteria. There were 207 patients in the omeprazole group (Group A) and 191 in the total fundoplication group (Group B). After applying the propensity score matching paired by Barrett's esophagus length, the groups were 180 (Group A) and 190 (Group B). Median follow-up was 80 months. Group B was significantly superior for controlling GERD symptoms. Group B was more efficient than Group A in promoting Barrett's esophagus regression or blocking its progression. Group B was more efficient than Group A in preventing the development of dysplasia and cancer. Logistic regression was performed for the outcomes of adenocarcinoma and dysplasia. Age and body mass index were used as covariates in the logistic regression models. Even after regression analysis, Group B was still superior to Group A to prevent esophageal adenocarcinoma or dysplasia transformation (odds ratio [OR]: 0.51; 95% confidence interval [CI]: 0.27-0.97, for adenocarcinoma or any dysplasia; and OR: 0.26; 95% CI: 0.08-0.81, for adenocarcinoma or high-grade dysplasia). Surgical treatment is superior to medical management, allowing for better symptom control, less need for reflux medication use, higher regression rate of the columnar epithelium and intestinal metaplasia, and lower risk for progression to dysplasia and cancer.

Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials.

Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.

Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study.

BACKGROUND AND STUDY AIMS: To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. PATIENTS AND METHODS: This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. RESULTS: Advanced duodenal polyposis was present in 13 patients (21 %; 9 male) at a mean age of 37.61 ±â€Š13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P  = 0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14 ±â€Š14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P  = 0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10 mm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3 %) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. CONCLUSIONS: Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.