Metaplastic columnar mucosa in the cervical esophagus after esophagectomy.
OBJECTIVE
To evaluate the pathogenesis of metaplastic processes within the esophagus using a human model in which the exact duration of reflux was known.


BACKGROUND
The pathogenesis of Barrett's esophagus (BE) is incompletely understood. Patients undergoing esophagectomy and gastric tube reconstruction represent a good model for studying the pathophysiology of columnar cell metaplasia of the human esophagus because the cervical esophagus is rarely or never exposed to gastric contents before the surgical procedure.


METHODS
Thirty-two patients underwent manometry, simultaneous 24-hour pH and bilirubin monitoring, and endoscopy with biopsy 3 to 10.4 years after esophagectomy. The presence of columnar mucosa in the cervical esophagus was confirmed on histologic examination. The findings on endoscopy and histology were related to clinical data and the results of pH and bilirubin monitoring 1 cm proximal to the esophagogastrostomy.


RESULTS
Fifteen (46.9%) of the 32 patients had metaplastic columnar mucosa within their cervical esophagus. Metaplasia was significantly more common in patients with a preoperative diagnosis of BE. The length of metaplastic mucosa correlated significantly with the degree of esophageal acid exposure, but the presence of abnormal bilirubin exposure was unrelated to the presence of metaplasia. The prevalence of metaplasia did not change with increasing time. Intestinal metaplasia was found within the columnar-lined segment in three patients 8.5, 9.5, and 10.4 years after esophagectomy. All patients with intestinal metaplasia had abnormal exposure of both acid and bilirubin, but the presence of combined reflux was not significantly higher in these patients compared with patients with nonintestinalized segments of columnar mucosa.


CONCLUSIONS
Esophageal columnar metaplasia is a common complication after gastric pull-up esophagectomy. Metaplasia is more likely to develop in patients with previous BE than other patients. Metaplasia develops in response to squamous epithelial injury in predisposed individuals.
Oberg
Stefan
S
Department of Surgery, Lund University Hospital, Lund, Sweden. stefan.oberg@skane.se
Johansson
Jan
J
Wenner
Jörgen
J
Walther
Bruno
B
D000230:Adenocarcinoma / Q000601:surgery; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000473:pathology / Q000601:surgery; D016099:Endoscopy, Gastrointestinal; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy; D004947:Esophagus / Q000473:pathology*; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008679:Metaplasia; D008875:Middle Aged; D009092:Mucous Membrane / Q000473:pathology; D011184:Postoperative Period