What preoperative and postoperative management is recommended for a patient with a history of concern for Barrett's esophagus who is undergoing hiatal hernia surgery and is currently on proton pump inhibitor (PPI) therapy, such as omeprazole (prilosec)?

Perioperative Management for Hiatal Hernia Surgery in Patients with Barrett's Esophagus

Continue PPI therapy throughout the perioperative period and indefinitely after hiatal hernia surgery, as antireflux surgery does not eliminate the need for ongoing Barrett's esophagus surveillance or acid suppression. 1

Preoperative Considerations

Confirm Barrett's Diagnosis and Dysplasia Status

• Ensure recent endoscopy with systematic biopsies has been performed to document the presence and extent of Barrett's esophagus and rule out dysplasia or early adenocarcinoma 1
• If dysplasia has been detected, the patient should be discussed at a specialist multidisciplinary team meeting before proceeding with hiatal hernia surgery 1
• Document the length of the Barrett's segment, as this influences cancer risk and surveillance strategy 1

Set Realistic Expectations About Surgery

• Inform the patient that antireflux surgery does not prevent progression to dysplasia or adenocarcinoma in Barrett's esophagus 1
• Controlled data show no change in the prevalence of Barrett's esophagus or incidence of adenocarcinoma when comparing surgical versus medical treatment 1
• The mortality risk from antireflux surgery exceeds the annual risk of death from esophageal adenocarcinoma in Barrett's patients 1

Appropriate Surgical Indications

• Antireflux surgery is appropriate for patients with Barrett's esophagus who have persistent troublesome symptoms (especially regurgitation) despite PPI therapy 1
• Surgery should be considered for patients who are intolerant to or have poor symptomatic response to PPIs 1
• Antireflux surgery should NOT be performed solely as an antineoplastic measure in Barrett's patients 1

Perioperative PPI Management

Continue Acid Suppression

• Maintain omeprazole 20-40 mg daily (or equivalent PPI) throughout the perioperative period 1, 2
• PPIs have the best clinical profile for symptomatic management and should not be discontinued 1
• Take omeprazole before meals as directed 2

Postoperative Management

Mandatory Endoscopic Surveillance

• After antireflux surgery, patients with Barrett's esophagus must continue the same endoscopic surveillance schedule as medically treated patients, regardless of surgical outcome 1
• A variable proportion (1-5%) of Barrett's patients can progress to high-grade dysplasia or carcinoma after antireflux surgery 1
• Surveillance intervals depend on Barrett's segment length and presence of intestinal metaplasia 1

Long-Term Acid Suppression

• Continue PPI therapy indefinitely after surgery for symptom control 1
• Use omeprazole 20 mg once daily for maintenance, or 40 mg daily if symptoms persist 1, 2
• Up to 30% of patients resume medical therapy by 5 years after antireflux surgery 1

Monitor for Surgical Complications

• Assess for new dysphagia, which may require esophageal dilation in approximately 6% of patients 1
• Monitor for increased flatulence, inability to belch, and bowel symptoms that commonly occur after fundoplication 1

Critical Pitfalls to Avoid

• Do not discontinue Barrett's surveillance after successful antireflux surgery—cancer risk persists 1
• Do not stop PPI therapy assuming surgery has "cured" the reflux—most patients require ongoing acid suppression 1
• Do not assume symptom resolution equals regression of Barrett's epithelium—endoscopic confirmation is required 3, 4
• Do not perform antireflux surgery in patients who are symptomatically well-controlled on medical therapy, as they have nothing to gain and incur added surgical risk 1