Background & Aims
Antireflux treatment is recommended to reduce esophageal adenocarcinoma in patients with Barrett’s esophagus. Antireflux surgery (fundoplication) counteracts gastroesophageal reflux of all types of carcinogenic gastric content and reduces esophageal acid exposure to a greater extent than antireflux medication (eg, proton pump inhibitors). We examined the hypothesis that antireflux surgery prevents esophageal adenocarcinoma to a larger degree than antireflux medication in patients with Barrett’s esophagus.

Methods
This multinational and population-based cohort study included all patients with a diagnosis of Barrett’s esophagus in any of the national patient registries in Denmark (2012–2020), Finland (1987–1996 and 2010–2020), Norway (2008–2020), or Sweden (2006–2020). Patients who underwent antireflux surgery were compared with nonoperated patients using antireflux medication. The risk of esophageal adenocarcinoma was calculated using multivariable Cox regression, providing hazard ratios (HRs) and 95% CIs adjusted for age, sex, country, calendar year, and comorbidity.

Results
The cohort consisted of 33,939 patients with Barrett’s esophagus. Of these, 542 (1.6%) had undergone antireflux surgery. During up to 32 years of follow-up, the overall HR was not decreased in patients having undergone antireflux surgery compared with nonoperated patients using antireflux medication, but rather increased (adjusted HR, 1.9; 95% CI, 1.1–3.5). In addition, HRs did not decrease with longer follow-up, but instead increased for each follow-up category, from 1.8 (95% CI, 0.6–5.0) within 1–4 years of follow-up to 4.4 (95% CI, 1.4–13.5) after 10–32 years of follow-up.

Conclusions
Patients with Barrett’s esophagus who undergo antireflux surgery do not seem to have a lower risk of esophageal adenocarcinoma than those using antireflux medication.