Joint Hospital Surgical Grand Round

United Christian HospitalDr C Leung

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

Background

Prevalence 1.6-5.6% 10-15% in patients with reflux symptoms

Premalignant condition 30-40 fold increased risk of oesophageal CA

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. Br J Surg 2006; 93: 1475-82

Pathogenesis

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

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

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. Am J Gastroenterol 2000; 95: 3089-95.

Treatment rationale

Removal of diseased mucosa, not entire organ

Prevent disease progression to adenoCA

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 controlCant reduce CA risk

HGD / Tis , T1a adenoCA

Multifocal, extensive HGD/ persistent HGD despite ablation/ ? CA

Acid Suppression with Surveillance Acid suppression will not eliminate

risk of adenocarcinoma/ consistent regression of Barrett’sDegree 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

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

PPI vs fundoplication

Surgery can definitely treat reflux-related symptoms, but its role in protection against adenocarcinoma should be cautiousEffectiveness in eliminating reflux symptomsCo- morbiditiesPatient’s choice/ complianceMedications S/E

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.

Argon Plasma Coagulation

Systemic review: more effective than PDT, 3-month complete eradication 80%

Less complications like stricture or bleeding

Odynophagia 10%

Li YM. Dig Dis Sci 2008; 53: 2837-46.

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

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

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

Radiofrequency ablation

Promising results S/E : esophageal stricture, GIB, chest

pain Sustaintially lower than those in

photodynamic therapy Long term data needed

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

Dumot JA. Gastrointest Endosc 2009; 70: 635-44.Shaheen NJ. Gastrointest Endosc 2010; 71: 680-5.

Endoscopic Mucosal Resection

when a visible nodule is present or only a short segment of Barrett’s is seen

substantial tissue for pathologist treat Tis or T1a adenocarcinoma Can combined with RFA

With submucosal invasion, 20% risk of LN

metIf confined to

mucosa ,<1% LN met

Endoscopic therapy

No single endotherapy achieve complete eradication without complications

Recurrence For mucosal lesion Buried metaplasia

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

SummaryBarrett’s

esophagus

metaplasia LGD HGD

Anti-reflux +surveillance OGD every3-5

year

Anti-reflux+OGD every 6-12

months

Repeat bx confirmed

HGDSend to expert

pathologist

Endotherapy (ablative/EMR/ESD)If persist/ ? CA then

esophagectomy

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