Management of Barretts Esophagus Joint Hospital Surgical Grand

Management of Barrett’s Esophagus Joint Hospital Surgical Grand Ground 17 th July 2010 Dr KS Chan Queen Elizabeth Hospital

Barrett’s Esophagus n n Metaplastic change in the distal esophageal lining Normal squamous epithelium replaced by columnar epithelium Named after Dr Norman Rupert Barrett q Incorrect description q “Congenitally short esophagus with tubular intrathoracic stomach” First description by Wilder Tileston dated back to 1906 Norman Rupert Barrett (1903– 1979)

n Prevalence q q n n 1. 6 -5. 6% in general population 10 -15% in patients with reflux symptoms Premalignant condition Associated with esophageal adenocarcinoma q q q 0. 5 -1% per patient-year 30 -40 fold increased risk compared to general population 10 -15% per patient-year in BE with high grade dysplasia

Risks factor n n n Gastroesophageal reflux Obesity Male sex Advanced age White race

Diagnosis n White light endoscopy q n Salmon-coloured epithelium projects into the tubular esophagus Systematic biopsy q q 4 quadrant biopsies every 2 cm in the columnar segment Additional biopsies from any mucosal abnormalities or visible lesions

Advances in Imaging n n n High resolution white light microscopy Chromoendoscopy Narrow band imaging Autofluorescence imaging Confocal laser endomicroscopy Spectroscopy

Management n n n Most patient with Barrett’s esophagus do not progress Confirm the diagnosis Non-dysplastic disease or low grade dysplasia q n Managed conservatively High grade dysplasia q q Increase risks of progression to cancer Intervention advocated

Treatment of Barrett’s Esophagus n Anti-reflux treatment q q n Endoscopic Therapy q q n Proton Pump Inhibitor Fundoplication Ablative: Photodynamic therapy, Argon plasma coagulation, laser, cryotherapy, radiofrequency ablation, mutlipolar electrocautery Resection: Endoscopic mucosal resection, Endoscopic submucosal dissection Surgical Therapy q Esophagectomy

Photodynamic Therapy n n Most extensively studied Use of photosensitizer which acculumates in malignant and pre-malignant tissue q n n n Porfimer sodium, aminolevulinic acid Exposure to light of appropriate wavelength Production of singlet oxygen and reactive oxygen species Cell damage and apoptosis

n n 69% of the subjects who received PDT developed photosensitivity reactions 36% developed esophageal strictures that required dilation therapy n First RCT showing reduction in adenocarcinoma risks in BE patients with any therapeutic intervention n 5 -ALA better tolerated with fewer complications

Radiofrequency Ablation n n High power radiofrequency energy generator, sizing balloon catheters and ablation catheters Penetration 0. 5 mm

n n n Treatment repeated every 2 -3 months All visible BE eradicated After final treatment session, biopsy taken over the original BE segment to exclude buried Barrett’s

n n Promising treatment modality Side effect q Esophageal stricture, GI bleeding and chest pain n Substantially lower than those in photodynamic therapy n Long term data needed

Endoscopic Resection n n Endoscopic Mucosal Resection (EMR) and Endoscopic submucosal dissection (ESD) Provide specimen for histopathological assessment Size of specimen resected by EMR limited to ~2 cm each attempt ESD enable en bloc resection of lesion regardless of size

EMR n n “Suck and cut” method Complications q q q Bleeding Perforation Stricture

Endoscopic Therapy n n n No single therapy achieve complete eradication without complications Recurrence Buried metaplasia q n Partially ablated Barrett’s epithelium healed with overlying squamous epithelium Applicable to lesion confined to mucosa only q Breach muscularis mucosae, >20% LN metastasis

Surgical Treatment n n n Esophagectomy considered as the ‘gold standard’ for high grade dysplasia and early adenocarinoma Morbidity and mortality Reported mortality rate ranges from 2% (Reed 2005), up to 20% post-operatively (Urba 2001)

Which is the best treatment? n n Currently no randomized controlled trials Only 6 restrospective, non-randomized trials q All with no significant difference in survival n Difficult to draw definitive conclusion n Should be individualized Considering age, co-morbidities, life expectancy and extent of disease n

Conclusion n n 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

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