Histologic Regression of Barrett’s Esophagus After Antireflux Surgery

OBJECTIVE: To evaluate the rate of Barrett's esophagus (BE) regression after antireflux surgery (ARS) and identify predictors of regression. SUMMARY OF BACKGROUND DATA: The impact of ARS on BE regression remains unclear. Defining the likelihood of intestinal metaplasia regression and identifying patients most likely to benefit may help guide postoperative surveillance. METHODS: Patients with biopsy proven BE undergoing fundoplication or magnetic sphincter augmentation (MSA) between 2013 and 2023 with ≥1-year endoscopic and histologic follow-up were included. Preoperative demographics, esophageal physiology, and endoscopic findings were compared between postoperative histologic regression and persistent BE using univariable and multivariable analyses. RESULTS: A total of 234 patients were included (163 fundoplication, 71 MSA). Histologic regression occurred in 53.4% overall, including 68.9% in ultrashort, 51.2% in short, and 0% in long-segment BE (P<0.001). Rates were similar between fundoplication and MSA (51.5% vs. 57.7%, P=0.396) but higher with an anatomically intact repair (64.2% vs. 38.8%, P<0.001). Independent predictors of regression were intact repair (OR 2.57, P=0.004), absence of severe esophagitis (OR 3.31, P=0.002), and shorter BE length (P<0.001). Patients without regression had a more severe reflux phenotype, including larger hiatal hernia, severe esophagitis, higher DeMeester score, and lower LES resting pressure (all P<0.05). CONCLUSION: Histologic regression of BE occurred in 53% of patients after ARS, confined to ultrashort and short segments, with no regression in long-segment BE. Intact repair was associated with regression, whereas disrupted repair was associated with segment lengthening. Regression appears to depend on restoration of an effective reflux barrier and underlying disease severity.