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One type of cancer of the esophagus, adenocarcinoma, is increasing more rapidly than any other cancer in both Western Europe and the US. Gastroesophageal reflux disease (GERD) appears to be an important risk factor (and possible cause) of this adenocarcinoma. It is believed that in GERD, injury to the cells lining the esophagus by refluxed acid causes the cells to change. The changes (referred to as Barrett's esophagus) make the cells more likely to become adenocarcinomas.
The approach to treatment of uncomplicated GERD (simple heartburn) is to control symptoms by controlling acid (medication) or reflux (surgery). Complications of GERD, such as Barrett's esophagus or scarring and narrowing of the esophagus, are treated with either aggressive control of the acid--irrespective of symptoms--or anti-reflux surgery (also known as fundoplication). It is recommended that patients who develop Barrett's esophagus should undergo regular screening with gastrointestinal endoscopy and biopsy so that adenocarcinoma can be discovered early and cured.
For many years, the standard surgical method for treating GERD involved a large incision in the upper abdomen. More recently, laparoscopic surgical techniques have been developed. Laparoscopic surgery requires only several small puncture wounds in the abdomen rather than a large incision. Laparoscopic surgery appears to be as effective as surgery utilizing large incisions, but results in less discomfort and a faster recovery. The relative comfort of laparoscopic surgery has prompted more patients with GERD to chose surgery over medication. The most recent techniques for treating GERD are endoscopic. (Endoscopy utilizes long tubes fitted with fiber-optics that can be swallowed. The fiber-optics allow the inside of the esophagus and stomach to be visualized without cutting them open. Small instruments also can be passed through channels in the tube to perform minor surgical procedures.) Endoscopic techniques are expected to be even more comfortable and have a faster recovery than laparoscopic surgery, but it is too early to know how effective endoscopic techniques will be.
Medication and surgery both are effective at controlling acid reflux and preventing GERD. Medication has the disadvantage of being expensive-probably more expensive than surgery-since it must be continued for life. Also, with medication, there is a potential problem with patients' compliance with treatment. Thus, patients may forget to take their medication or they may take it only when they have symptoms. (Symptoms are a poor indication of the amount of damage that acid is inflicting on the esophagus, since much of the damage is done when symptoms are minimal or absent.) For this reason, it often is argued-especially by surgeons-that surgery is the preferred treatment for chronic GERD, especially for patients with Barrett's esophagus who are at risk for adenocarcinoma. A corollary to this argument that is sometimes made is that surgery, because it may get around the problem with compliance, may be more effective than medication at reducing the risk of adenocarcinoma. Moreover, surgeons argue that refluxed materials other than acid (e.g., bile) also may be important in the development of adenocarcinoma, and that surgery will prevent the reflux of all materials, not just acid. It has not been shown, however, that the control of acid or reflux by medication or surgery can prevent adenocarcinoma.
In December, 2001, an important study was published in the medical journal, Gastroenterology. This study was designed to explore the question as to whether antireflux surgery can prevent adenocarcinoma of the esophagus. The study was a retrospective, epidemiologic study. (Epidemiologic studies are studies that involve large numbers of patients.) It was done in Sweden and involved virtually the entire population of Sweden, thereby making it a very powerful study. The study compared the risk of developing adenocarcinoma of the esophagus among patients with GERD, patients with GERD who underwent antireflux surgery, and the entire population of Sweden. The study's investigators found that the risk of adenocarcinoma of the esophagus was six times higher in patients with GERD than in the general population, which supports previous studies that linked adenocarcinoma to GERD. However, the investigators also found that patients with GERD who underwent antireflux surgery continued to be at high risk for adenocarcinoma of the esophagus. In other words, surgery did not protect them from adenocarcinoma.
This study is the most authoritative epidemiologic study to date and is unlikely to be equaled in the future. Nevertheless, epidemiologic studies cannot determine cause and effect or prove an hypothesis (i.e., whether antireflux surgery can or cannot prevent adenocarcinoma.) For a definitive conclusion about the role of surgery in the prevention of adenocarcinoma of the esophagus, a prospective study (one that follows patients from the time of surgery) will need to be conducted. Such a study will require large numbers of patients with GERD to be randomized to either receive or not receive antireflux surgery. The patients then will need to be followed for many years. Such a study would tell us definitively whether or not antireflux surgery can prevent adenocarcinoma of the esophagus. (If a third group were added, a group treated aggressively with medication, we also would learn if aggressive treatment with medication can prevent adenocarcinoma.)
What conclusion should be drawn from the study in Gastroenterology? The most
important one is that there is strong epidemiologic evidence that antireflux
surgery does not prevent adenocarcinoma of the esophagus. What practical
conclusion can be drawn from the study? The choice of treatment for
GERD--medication or surgery--should be made by each patient based on his or her
own particular circumstances and desires. Patients should not, however, choose
surgery because it reduces the risk of adenocarcinoma.
Medical Author: Jay Marks, M.D.
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR
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