Indications for Anti-Reflux Surgery in Barrett's Esophagus

Dear Editor,

In the Editorial from the May issue of Cirugía Española, Ruiz de Angulo et al. pose the question of whether surgical indications should be extended in Barrett's esophagus after considering the recent publication in JAMA about the secondary effects of long-term proton pump inhibitor (PPI) use (particularly with regards to possible vitamin B₁₂ deficiency).^1,2 In a very balanced manner, and based on the great experience that the group from Arrixaca has in gastroesophageal reflux (GERD) surgery, the authors calm the concerns caused by the JAMA publication, and they indicate that they do not have any data about any significant undesired effects induced by PPI. In fact, given the growing proportion of long-term takers of PPI (with or without justified indications), even with high doses of PPI and the stable prevalence of vitamin B₁₂ deficiency in Europe it seems that we need not worry.³

But, there are two other arguments for not extending the indications in Barrett's esophagus: on the one hand, several robust, recent studies show that the risk for malignant transformation is much lower than what was previously believed; on the other hand, the long-term results of anti-reflux surgery are not as good as in the short term (particularly with regards to reflux control, reversal of Barrett's esophagus, or even dysplasia).^4,5 Recent recommendations from endoscopy and digestive tract societies consider reducing vigilance in Barrett's esophagus.⁶

Thus, although we are surgeons and want to preserve our profession, I believe that today it is necessary to modify and reduce the indications for anti-reflux surgery.