Address correspondence to: Sergio Szachnowicz, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP 05403-000, Brazil. Email: sergioszac@gmail.com Conflicts of interest: The authors declare that they have no conflict of interest. © The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Diseases of the Esophagus (2022), 35, 1–8 https://doi.org/10.1093/dote/doac026 Original Article Laparoscopic total fundoplication is superior to medical treatment for reducing the cancer risk in Barrett’s esophagus: a long-term analysis S. Szachnowicz, 1, * A.F. Duarte, 1 A. Nasi, 1 J.R.M. da Rocha, 1 F.B. Seguro, 1 E.T. Bianchi, 1 F. Tustumi, 1 E.G.H. de Moura, 2 R.A.A. Sallum, 1 I. Cecconello 1 1 Digestive Surgery Division, Department of Gastroenterology, Universidade de Sao Paulo, São Paulo, Brazil and 2 Endoscopy Unit – Digestive Surgery Division, Department of Gastroenterology, Universidade de Sao Paulo, São Paulo, Brazil SUMMARY. 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. KEY WORDS: adenocarcinoma, Barrett’s esophagus, fundoplication, gastroesophageal reflux, proton pump inhibitors. INTRODUCTION Barrett’s esophagus (BE) is commonly associated with gastroesophageal reflux disease (GERD). After cumulative mutations, it is prone to development of dysplasia and cancer of the esophagus. 1 A compre- hensive population study carried out in Denmark found a 0.12% per year risk for adenocarcinoma in patients with BE. 2 The main goals of BE treatment are to con- trol GERD and its associated symptoms, reduce the aggression of the esophageal mucosa, reduce esophageal lesions, and decrease the risk for progres- sion of epithelium dysplasia to adenocarcinoma. 3 Esophageal mucosa damage and evolution to Barrett’s and cancer take time, 4 and consequently, the success of any BE treatment should be based on long- term analysis. Clinical treatment is the most common approach to control GERD in patients with BE. 5 Currently, the most frequently used class of drug is the proton pump inhibitor, which acts by decreasing the intensity of the acidity in the stomach lumen without changing the occurrence of gastroesophageal reflux. 6 Surgical treatment for GERD is another option for BE patients. Fundoplication can block and not just change the endoluminal pH. 7 , 8 Thus, the damage done by biliary reflux, unlike in medical therapy, can be mitigated. 9 Moreover, surgical intervention can correct anatomical abnormalities, such as the hiatal hernia, and control the hypotonic lower esophageal sphincter and its transient relaxation, which may con- tribute to reflux. 7, 8 The present study aims to compare the effective- ness of surgical and medical therapy in controlling the BE epithelium and reducing the risk for dysplasia and cancer in BE in a long-term evaluation. 1 Downloaded from https://academic.oup.com/dote/article/35/11/doac026/6596311 by guest on 14 January 2024