Management of Barrett’s oEsophagus
description
Transcript of Management of Barrett’s oEsophagus
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