Surgery in Barrett's oesophagus.

Surgical treatment for a columnar-lined oesophagus (CLO) may be considered in terms of indications, procedures and risks. Reflux may be an indication for surgery, but does not lead to reversal of epithelium, nor does it eliminate malignant potential. Whether it reduces such potential is not certain. Anti-reflux surgery is therefore based on reflux-related criteria, and not as a treatment for a CLO. Dysplasia is a possible indication for surgery, but as progression to carcinoma may be slow, must not be considered an absolute indication in an elderly, frail patient. Malignancy is a clear indication for operation in a patient deemed fit enough to withstand it. Anti-reflux operations have been standardized over recent years, and aim at exclusion of gastric juice from the oesophagus. Another approach is to alter refluxed material qualitatively by a duodenal diversion procedure. This eliminates bile and pancreatic juice from the oesophagus, with dramatic effects on inflammation but without reversal of a CLO. Reversal of inflammation may facilitate endoscopic surveillance. Either dysplasia or carcinoma are treated by oesophagogastric resection. Newer forms of laparoscopic or thoracoscopic dissection may be particularly applicable with dysplasia or early carcinoma in CLO. Palliative surgery for advanced tumours is not often required today. Risks of anti-reflux surgery must be balanced against symptoms. Risks are reduced if splenectomy is avoided, and operations avoided where possible in the elderly. Resection for dysplasia or carcinoma is high-risk surgery. In the young there is much to gain, and the risks are lower. In the elderly, in the absence of other treatment, risks must be balanced against general health and life expectancy.