Barrett's esophagus

1. MANAGEMENT OF
BARRETT’S OESOPHAGUS
Joint Hospital Surgical Grand Round
United Christian Hospital
Dr C Leung

2. Definition
 A change in the normal squamous epithelium
of the oesophagus to specialized intestinal
metaplasia
Playford RJ. New British Society of Gastroenterology guidelines for the
diagnosis and management of Barrett’s esophagus
Gut 2006;55:442-3

3. Background
 Prevalence
1.6-5.6%
 10-15% in patients with reflux symptoms
 Premalignant condition
 30-40 fold increased risk of oesophageal CA

4. Etiology
 Combined acid and bile reflux
 > 50% of patients with GERD had abnormal
levels of acid and bile in the oesophagus
 Barrett’s esophagus patients have the highest
level
Fein M. BrJ Surg 2006; 93: 1475-82

5. Pathogenesis

6. Risk of Adenocarcinoma
 0.25 to 0.4% per year
 Nondysplasic : 3.86/1000 person years
 Low-grade dysplaia: 7.66/1000 person years
 High-grade dysplasia
Occult carcinoma: 30%-40% of patients
 14.1/100 person years
Sharma P. Clin Gastroenterol Hepatol 2006; 4: 566-72
Buttar NS. Gastroenterology 2001; 120: 1630-9

7. Endoscopic Evaluation
 Prague classification
 the maximal length (M)
(including tongues) of
Barrett esophagus
 length of the
circumferential Barrett
segment (C)
 For future endoscopic
comparison
Sharma P. Gastroenterology 2006; 131: 1392-9

8. Biopsies
 Seattle protocol
 4 quadrant jumbo bx at 1cm intervals throughout
whole length of Barrett’s
 Separate target bx of any irregularities
(nodules/erythema/ erosions)
Reid BJ. AmJ Gastroenterol 2000; 95: 3089-95.

9. Treatment rationale
 Removal of diseased mucosa, not entire
organ
 Prevent disease progression to adenoCA

10. Treatment Options
 Anti-reflux treatment
-PPI
-Fundoplication
+/- surveillance
 Endoscopic
ablation
 Photodynamic therapy (PDT)
 Multipolar electrocoagulation
 Argon Plasma Coagulation
 Radiofrequency ablation (RFA)
 Cryoablation
resection
 EMR/ ESD
 Esophagectomy
Symptomatic control
Cant reduce CA risk
HGD /Tis ,T1a adenoCA
Multifocal, extensive
HGD/ persistent HGD
despite ablation/ ? CA

11. Acid Suppression with
Surveillance
 Acid suppression will not eliminate risk of
adenocarcinoma/ consistent regression of
Barrett’s
Degree of dysplasia Surveillance OGD interval
Non-dysplastic 3-5 year
Low grade dysplasia 6-12 months
High grad dysplasia Interval 3 months (if patient not
receive invasive therapy)
? Duration and dosage
of PPI (indefinite)
?optimal frequency of
surveillance

12. Anti-reflux Surgery
 Fundoplication eliminates acid and bile reflux
in > 90% of patients with Barrett’s
oesophagus
 Meta-analysis: 15.4% of patients undergone
surgery will have regression of Barrett’s vs.
1.9% medically managed patients
 Swedish Cohort study showed that RR of
adenocarcinoma in patients undergone
surgery was 14.1 vs. 6.3 for medical treatment
Oelschlager BK. Ann Surg 2003; 238: 458-64.
Chang EY. Ann Surg 2007; 246: 11-21.
Lagergren J. Gastroenterology 2010; 138: 1297-301
Reduce risk of adenoCA ?
Mixed evidences so far

13. PPI vs fundoplication
 Surgery can definitely treat reflux-related
symptoms, but its role in protection against
adenocarcinoma should be cautious
Effectiveness in eliminating reflux symptoms
Co- morbidities
Patient’s choice/ compliance
Medications S/E

14. Photodynamic Therapy
 Injecting a light-sensitizing drug into patient,
then expose the portion of oesophagus to a
specific wavelength
 Found NOT effective in eliminating Barrett’s
 ‘Buried glands’: a layer of normal-appearing
squamous epithelium is present but under
this layer, Barret’s metaplasia still present
 Stricture
 Phototoxicity
Menon D. BMC Gastroenterol 2010; 10: 111.

15. Argon Plasma Coagulation
 Systemic review: more effective than PDT, 3-
month complete eradication 80%
 Less complications like stricture or bleeding
 Odynophagia 10%
LiYM. Dig Dis Sci 2008; 53: 2837-46.

16. Radiofrequency Ablation
 One of the best studied method
 Applies bipolar electrical energy to mucosal
surfaces, 10J for 1 second  mucosa is ablated
to submucosal level

17. Radiofrequency ablation
 Need standardized FU as complete ablation
with single treatment in only 70% of patients
 FU OGD 3 months and 1 year, if not complete
ablated  repeat RFA

18. Radiofrequency ablation
 Shaheen NJ (2009): Multicentre RCT
 Can eliminate Barrett’s oesophagus with high grade
dysplasia and reduce risk of oesophageal carcinoma
 Wani S (2009): Meta-analysis
 Reduction in carcinoma progression in high-grade
dysplasia
 Shaheen NJ (2011): Long term results
 3 years follow-up: complete eradication persist in
96% patients with high-grade dysplaia
 Adenocarcinoma occurred in one per 181 patient-
years of follow-up

19. Radiofrequency ablation
 Promising results
 S/E : esophageal stricture,GIB, chest pain
 Sustaintially lower than those in
photodynamic therapy
 Long term data needed

20. Cryoablation
 Endoscopically directed spray of liquid nitrogen
at -196oC
 Complete eradication of high grade dysplasia
occurs in 68-97% of patients
 Not well studied as RFA
 ?Treat patient refractory to RFA
DumotJA.Gastrointest Endosc 2009; 70: 635-44.
Shaheen NJ.Gastrointest Endosc 2010; 71: 680-5.

21. Endoscopic Mucosal Resection
 when a visible nodule is present
or only a short segment of Barrett’s
is seen
 substantial tissue for pathologist
 treatTis orT1a adenocarcinoma
 Can combined with RFA
With submucosal invasion,
20% risk of LN met
If confined to mucosa ,<1% LN
met

22. Endoscopic therapy
 No single endotherapy achieve complete
eradication without complications
 Recurrence
 For mucosal lesion
 Buried metaplasia

23. Esophagectomy
 ‘gold standard’ for high grade dysplasia and
early adenocarinoma
 20-40% of patients harbour early
adenocarcinoma in HGD (old data)
 Mortality can be as low as 1% in high vol
centre
 Significant morbidity
 For multifocal , too extensive HGD /
intractable HGD /suspicious of carcinoma

24. Summary
Barrett’s
esophagus
metaplasia LGD HGD
Anti-reflux
+surveillance
OGD every3-5
year
Anti-reflux+OGD
every 6-12 months
Repeat bx
confirmed HGD
Send to expert
pathologist
Endotherapy (ablative/EMR/ESD)
If persist/ ? CA then
esophagectomy

25. Take Home Messages
 Barrett’s esophagus is a pre-malignant
condition
 Diagnosis relies on both endoscopic and
histological findings
 Management should be based on risks
stratification
 Emerging evidence on the use of endoscopic
therapy
 Treatment should be individualized