Understanding Barrett's Esophagus

Barrett’s esophagus (BE) or intestinal metaplasia (IM) is a change in the epithelial lining of the esophagus. BE develops as a result of chronic exposure of the esophagus to refluxed stomach acid, enzymes and bile.  
It occurs when a patient’s lower esophageal sphincter or valve no longer closes properly to prevent acid backwash into the lower esophagus. This results in recurrent mucosal injury. Such injury is accompanied by inflammation, and ultimately a cellular change (metaplasia) to a specialized columnar epithelium.¹⁹
Gastroesophageal reflux disease or GERD is a chronic form of heartburn, which according to a Harvard Medical School Report, affects 10% of Americans on a daily basis.³⁵ Acid related diseases are climbing in severity and they are a growing cause of sleep problems and work absences. This indicates an increasing need for early intervention, prevention and therapeutic services for this and other digestive concerns.
Chronic heartburn, being the leading cause of Barrett’s esophagus,³¹ is a digestive concern that requires understanding and about which the public should be made more aware, as it is the beginning of a potential progression toward esophageal cancer.³²
According to the American Gastroenterological Association (AGA), which published a Medical Position Statement on the Management of
Barrett’s esophagus in March 2011, endoscopic eradication therapy – such as radiofrequency ablation (RFA) – for patients with confirmed high-grade dysplasia (advanced precancerous cells) is recommended instead of surveillance or immediate esophagectomy.
For patients with confirmed low-grade dysplasia (less advanced precancerous cells), endoscopic eradication therapy is recommended as a therapeutic option, and it should be discussed as such with patients. For patients with non-dysplastic (early precancerous cells) Barrett’s, the AGA states:

“Although endoscopic eradication therapy is not suggested for the general population of patients with Barrett’s esophagus in the absence of dysplasia, we suggest that RFA, with or without endoscopic mucosal resection (EMR), should be a therapeutic option for select individuals with nondysplastic Barrett’s esophagus who are judged to be at increased risk for progression to high-grade dysplasia or cancer.”

The AGA goes on to reinforce the importance of a…

“…shared decision making where the treating physician and patient together consider whether endoscopic surveillance or eradication therapy is the preferred management option for each individual.”

Incidence

• In a study published in 2005, BE’s prevalence was estimated to affect 3.3 million adults over 50 years of age in the United States.^3,14,36
• The prevalence of BE in the adult population is 0.4% to 1.3%, although recent reports from gastroenterology-selected populations suggest a higher prevalence.⁵

Barrett's and Esophageal Adenocarcinoma

• From 1975 to 2001, the frequency of esophageal adenocarcinoma rose approximately six fold in the U.S. from four to 23 cases per million people. At the same time, the rate of deaths due to this form of esophageal cancer has grown seven fold, from two to 15 deaths per million people.⁴
• Patients with Barrett’s esophagus have an increased risk of developing esophageal adenocarcinoma⁶ at a rate that is 30 to 125 times higher than patients without this condition.⁷
• The American Cancer Society estimates that during 2010, approximately 16,640 new esophageal cancer cases were diagnosed.⁸
• Even with aggressive therapy, the five-year survival rate from adenocarcinoma is only around 17%.⁸

Gastroesophageal Reflux Disease (GERD) and Barrett's Esophagus 

• Approximately 13% of Caucasian men over age 50 who have chronic reflux will develop Barrett’s esophagus.⁴
• In a study conducted by the Veteran Affairs Health Care System and Stanford University, 25% of patients over 50 years old without acid reflux symptoms were found to have Barrett’s esophagus.¹⁴
• GERD is common in the U.S. adult population. Symptoms of acid reflux, including heartburn, occur: 
• Weekly in 18% of U.S. adults¹⁶
• Monthly in almost 44% of U.S. adults¹⁶

"The presence of Barrett’s esophagus is considered to be the primary risk factor for developing esophageal cancer."

Johnston, et al 2008

 http://www.barrx.com/healthcare-professionals/why-treat-barretts-esophagus.php

Very Informative

I came across this power point presentation today when researching a list of doctors recommendations for post op diets. I found it to be informative and answers many questions. Hope it does the same for you. University of Kentucky Medical School

Post op Diet via the web

What the doctors say... Here are just a few links for post op diets

Winchester Surgeons at 83 Memorial Drive · Winchester, TN 37398

Robert A. Catania, MD, FACS with the Department of General Surgery @ the Naval Medical Center Portsmouth


NEWTON-WELLESLEY SURGEONS, INC. at 2000 WASHINGTON STREET, SUITE 365 in NEWTON, MA 02462

Livestrong website Livestrong website via the web

UCLA Center for Esophageal Disorders

The Harbin Clinic located in Georgia

University Of Virginia

Aaron S. Bransky, MD located at 6309 Preston Road, Suite 1200 Plano, Texas 75024

University of North Carolina School of Medicine

UPMC is  Affiliated with the University of Pittsburgh Schools of the Health Sciences 

Living with Reflux website

University of Michigan Health System

For a list of Aurora facilities with a dietitian, please call Aurora Health Care toll free at 888-863-5502.

What is a Nissen Fundoplication

What is a Nissen fundoplication it is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Belsey fundoplication (270° anterior transthoracic), Dor fundoplication (anterior 180-200°) or Toupet fundoplication (posterior 270°) are also alternative procedures with somewhat different indications.

Who invented or preformed the first procedure - Dr. Rudolph Nissen (1896–1981) first performed the procedure in 1955 and published the results of two cases in a 1956 Swiss Medical Weekly.^[1] In 1961 he published a more detailed overview of the procedure.^[2] Nissen originally called the surgery "gastroplication." The procedure has borne his name since it gained popularity in the 1970s.


What type of techniques are used to preform this surgery -In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm. In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus. The procedure is now routinely performed laparoscopically and robotically using the da Vinci Surgery System. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty.

You should feel relief because - Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid (in GERD).

Some complications have been reported such as -Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.^[4] Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, vagus nerve injury, and rarely, achalasia.^[5] The fundoplication can also come undone over time in about 5-10% of cases, leading to recurrence of symptoms. If the symptoms warrant a repeat surgery, the surgeon may use Marlex or another form of artificial mesh to strengthen the connection.^[6] Postoperative irritable bowel syndrome, which lasts for roughly 2 weeks, is possible. In "gas bloat syndrome", fundoplication can alter the mechanical ability of the stomach to eliminate swallowed air by belching, leading to an accumulation of gas in the stomach or small intestine. Data varies, but some degree of gas-bloat may occur in as many as 41% of Nissen patients; whereas the occurrence is less with patients undergoing partial anterior fundoplication.^[7] Gas bloat syndrome is usually self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may also come from dietary sources (especially carbonated beverages), or involuntary swallowing of air (aerophagia). If postoperative gas-bloat syndrome does not resolve with time, dietary restrictions, and counselling regarding aerophagia; correction may be necessary, either by endoscopic balloon dilatation^{[citation needed]} or repeat surgery to revise the Nissen fundoplication to a partial fundoplication.^[7] Vomiting is often difficult or even impossible with a fundoplication. In some cases, the purpose of this operation is to correct excessive vomiting. However, when its purpose is to reduce gastric reflux, difficulty in vomiting may be an undesired outcome. Initially, vomiting is impossible; however, small amounts of vomit may be produced after the wrap settles over time, and in extreme cases such as alcohol poisoning or food poisoning, the patient may be able to vomit freely.


  

NF surgery

This is a video uploaded unto YouTube via Tampa General Hospital all rights belong to them. I have watched several videos on this surgery and have found that this one proved to be the most informative. It is a little long at just over an hour. But in reality that is how long the procedure takes. The surgeon and the narrator answer questions during the video of the surgery. Please follow this link to the YouTube site -  http://www.youtube.com/watch?v=pa-b1-5SMKw&noredirect=1

Day 34

Today so far has been a really good day. I have tried to introduce some activities that I previously enjoyed back into my daily life. Although I am tired I do not feel that I have overdone it or by any means hurt the outcome of my surgery. Today I have heartburn free and reflux free. I do not believe I will ever be gas free, one can only hope.

Welcome

Just a little note about me; my name is Jess. I am a 36 year old wife and stay at home mother of three boys.  I had a laparoscopic Nissen Fundoplication on Friday February 24, 2012.

Several years back I presented in the ER with severe abdominal pain. I was diagnosed with gallstones and sent home by the PA who told me people live with stones for years with no trouble. I promise I will get to the NF part. Back in September I was admitted to the Hospital with severe abdominal pain w/ a history of gallstones. The doctors ordered every test imaginable to tell me I had stone and to almost send me home again. I begged and pleaded with my doctor whom I had never met before; we had just moved to a new area and I had not yet established a new doctor, to please order a surgical consult. It must have been the tears because he did. In walks my angel later that day. My surgeon asked in depth as to what I had been going through for the past several years. He stated he didn’t know if the pain was only from the stones or if there was another underlying issue that needed to be addressed, this was on a Wednesday. He ordered that I have endoscopy done so on Thursday morning I was on my way to discovering my fate.  I had already had – x-rays, barium swallow, CT, MRI, Ultrasound, PET scan and some other test down in nuclear medicine what was one more. On the way back up to my room the nurse informed me that they discovered some irregularities and more samples are being sent off to be biopsied. On Friday I was stone free and what I thought to be healed. The test results came back with not so good new…so the past 6 months have been very difficult for me and my family. On a good note my last tests reveals the presence of only Barrett’s Esophagus w/ low grade dysplasia.

Prior to my surgery: 

1st issue - See I have always had trouble swallowing even at a young age. My husband says I am the only person he knows that can choke on their own saliva. Which I did all the time, I can have nothing in my mouth and start choking. I choke and cough all the time. I always said it was from cheerleading cause I yelled all the time I must have damaged my throat. I have always felt like I feel like I have a cotton ball stuck in my throat.

2nd issue – this pain in my chest and abdomen, oh my lanta. I have it all the time and it gets worse. I know many others have felt it too. It lasts 15-30 minutes and feels like someone is stabbing me with a knife. I find myself only wearing loose fitting clothes now so that they don’t put pressure on my chest. I have been on acid blockers twice a day (two in the am and two at night) for 3 years with no relief. Until I met my surgeon no one believed that this could be.

3rd issue – this gas... See I was raised by a southern woman and you just don’t have these issues. I literally didn’t know how to burp till I was 25. I never fluffed in front of my husband or anybody else for that matter. Now, I have no control. My kids think it is the grossest thing ever. I am so sorry to right about this – that is enough about that subject you get the point.

My symptoms kept getting worse. So this angel I spoke of earlier my surgeon he just moved to my area and one of his specialties is NF. I did a lot of research online and we decided that this was the best option for me.

So onto more tests and more answers:

My Minometry revealed – my esophagus works overtime - but it works, I can swallow when I shouldn’t be able to, my esophageal sphincter does not work properly and to top it off I have a hiatal hernia.

Surgery Day - February 24, 2012 - Today is the day.. I am a little scared as I have been reading up on this procedure for what seems like forever. Kids up and off to school and I'm showered and dressed, off we go. 10:30ish I am in the pre-op room speaking with the nurses and my family (dad & step mom and hubby are all here) time to go to the next staging/ holding room as I call it. Kisses and hugs and here I go.. all the reading up is about to come true for me. It all happened so quick...In walks my anesthesiologist - hello I'm going to start a arterial line do to the position you will be in during the surgery. Just to make sure we have accurate readings.."ok"..line in, meds for my anxiety in and away I go..Operating Room - Everyone introduces themselves and I move over to the table and He says goodnight..Post-op; I don't see anything familiar to me, it's not the same as last time there is a lot more craziness going on. The nurse is talking to me but I don't see anything familiar. Wait I see "s" I always see him as I'm waking up. I'm ok I ask him to please tell someone that I'm ok and I made it through. He smiles - I think he thinks I'm crazy. The next thing I remember is being in my room with my family, my mom is here now. The pain is not that bad, I can handle this. My family and friends come and go I'm still a little groggy and not to sure whats going on. I know I should get up, my brother helps me up and to walk to the bathroom - no luck what is going on. Shift change a it's around 11 pm. What a crazy day...I can feel the pain and It hurts.. night shift is understaffed and not very friendly. They don't understand why I don't feel good. Ouch!!! I try to get myself up and i must have pulled something this new pain on my right side is killing me..push the call light no answer. I am so uncomfortable..stop it you just got out of surgery don't try and over so it. Push the call light again, he gets me up and I'm unable to use the restroom again. I'm in so much pain. Please send in the nurse - two hour past and no nurse, call light again - no nurse, call light again it's 5 am and I haven't been able to sleep. In walks another nurse from the floor - why do you keep pushing your call light your nurse is busy with other patients. I'm in pain and I haven't been able to urinate I tell her. She tells me that I am wrong and I have urinated 2 times. I thing I would know I tell her. So she does and ultrasound sure enough I have 600+cc's - me I told you so. Next time please listen to me. The next morning my nurse was great, she floated from another floor. She got me up and walking around, cleaned up and catheter out. It's a waiting game I have to pee on my own and she will send me home. It was all in my head I couldn't pee over the hat, once I removed it relief. It took me a couple of days to be able to use the restroom normally.
Recovery Begins: February 25, 2012 - released from the hospital and one my way home. When I got home my amazing husband had bought me my recliner (with heat and massage) What an amazing chair I spent almost all of my time in it. It hurts to walk upright these days. My pain is mostly gas pain, I think. My belly is tender and is in some pain. I am taking 2 - oxycodone 5 mg for pain every 4 hours. I have to crush the meds as I am unable to swallow any pills. I took my meds with a little bit of applesauce this seems to not bother my stomach. For the next few days I am in quite a bit of pain and having trouble sleeping. My pain level is about a 5 on a scale of 1-10.
Follow up:  My doctor says everything looks good and my sites are healing nicely. Just a couple of little scars. I mention my pain on the right side it feels like I have pulled a muscle. He says it might be from him. But, I remember when I pulled it in the hospital so that ones on me. Other then that NO pain and things are looking good. No heartburn, no reflux and no cancer. Life is good...
Just a little Scare: The pain on my right side continues and my doctor sends me for a stat CT scan. Please let your doctor know if there is any change in your pain level or if new pain arises. He thought I might have a blood clot..I don't better safe then sorry. Not fun trying to drink the contrast 16 oz I have only been able to take in about 6 oz at a time.
Activities: Things are not back to normal yet. I am trying my best to do things that I did before. No lifting over 10 lbs, walking a little it still hurts my side and I get tired real easy. 
Diet: Please see my page on my diet