Endoscopic Eradication Therapy for Barrett’s Esophagus
Barrett’s Esophagus Endoscopic Eradication Therapy
Short-segment Barrett’s esophagus.
Esophageal cancer is considered the fastest rising cancer at this time in the United States.
Barryx Halo 360 Balloon Catheter
Barryx 90 RFA Focal Catheter
By John Petersen, D.O., F.A.C.P, F.A.C.G.
Barrett’s esophagus is the precursor lesion to esophageal adenocarcinoma which if diagnosed at an invasive stage, is associated with significant morbidity and mortality. Surgery has been the main stay of treatment for patients with Barrett’s esophagus associated high grade dysplasia (HGD) and carcinoma. However, surgery can carry significant morbidity and potential mortality. In the last decade, tremendous progress has been made in the minimally invasive treatment of Barrett’s esophagus using a variety of endoscopic techniques that are available through the Borland-Groover Clinic.
Barrett’s esophagus is the displacement of the squamocolumnar junction by intestinal metaplasia proximal to the gastroesophageal junction. In patients with Barrett’s esophagus (BE), the annual incidence of esophageal adenocarcinoma is reported to be between 0.1% and 0.5%. Specialized intestinal metaplasia (BE) can have a histologic transforation that goes from no dysplasia to low grade dysplasia (LGD) to HGD, and eventually esophageal adenocarcinoma. Therefore, endoscopic eradication therapy is being used commonly now through the Borland-Groover Clinic to treat HGD and early esophageal cancer to decrease the risk to progression to invasive malignancy. Esophageal cancer is considered the fastest rising cancer at this time in the United States.
The aim of ablation or eradication therapy in the esophagus containing Barrett’s esophagus is to destroy this abnormal lining of the esophagus and reinstate growth of new squamous lining. The rate of progression to cancer or even advanced dysplasia in non-dysplastic BE is extremely low. However, the combined incidence of HGD and esophageal adenocarcinoma can be as high as 2% per year with a mean time to progression to esophageal cancer of only 4.4 years. It is a little bit unclear at this time the rate and frequency of progression of LGD to HGD. At this point in time, a recent metaanalysis revealed a high incidence of esophageal adenocarcinoma in patients with HGD who had not undergone ablation therapy or surgery. This can be as high as 6% per year. If untreated, HGD is associated with a significant risk for progression to cancer. It is for these reasons that endoscopic eradication therapy has become extremely popular and widely practiced at the Borland-Groover Clinic.
In order to obtain accurate staging of visible lesions and cancer, it is oftentimes necessary to perform endoscopic mucosal resection (EMR). This tells us the depth of invasion of potential dysplastic epithelium and malignancy. Endoscopic ultrasound also compliments this resection. There are 3 main categories of endoscopic eradication therapy for Barrett’s Esophagus.
- First, thermal ablation therapy which includes multipolar electrocoagulation, Argon plasma coagulation, and certain forms of laser therapy.
- The second, non-thermal ablation which includes photodynamic therapy which has lost interest in recent years because of significant complications and lack of efficacy, radiofrequency ablation which is the most widely used form of ablation at the Borland-Groover Clinic, and cryotherapy which is utilized at Baptist Hospital.
- The third modality is endoscopic resection which includes endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).
Success with the use of EMR is significant with these lesions containing high grade dysplasia and localized T1A malignancy. Complications are quite infrequent with both EMR and more aggressive ESD. The use of radiofrequency ablation has been used for many years through our clinic and Baptist Hospital. Radiofrequency ablation (RFA) can be delivered using a circumferential or a focal device. Short term and long term results are outstanding. This modality is an outpatient technique that is used to treat high grade dysplasia and these localized T1A esophageal malignancies. At this moment, it cannot be recommended for patients with non-dysplastic Barrett’s esophagus and the debate goes on how to optimally manage those patients with low grade dysplasia which of course can indeed progress. Complete eradication of BE and RFA is in the range of 70-93%. Eradication of dysplasia is nearly 100%. Complications are quite infrequent including bleeding, chest pain, esophageal strictures, or the appearance of buried glands of Barrett’s esophagus below the area of treatment as it fills and heals over months and years.
Cryotherapy is a relatively new technique that is being used at the present time at Baptist Hospital. Freezing of the epithelium can be done quite effectively. The advantages of cryotherapy over other ablative techniques are that it is easy to cover larger area of the mucosa causing tissue destruction without precise close contact, Short term results are encouraging. A number of sessions may be necessary to treat high grade dysplasia or early esophageal cancers. Eradication rates have been reports as high as 96%. Complications again seem to be quite minimal.
In summary, current evidence suggests that multimodal endoscopic eradication therapy with focal EMR and RFA is the best treatment for Barrett’s Esophagus with high grade dysplasia and localized T1A esophageal adenocarcinoma. Cryotherapy appears promising. Continued surveillance after eradication is mandatory. Barrett’s Esophagus continues to be a significant challenge to all gastroenterologists as the Borland-Groover Clinic. We will continue to stay on the cutting edge of technology as it applies to this very important and potentially premalignant lesion.