Barrett's Esophagus Denver
The inner lining of your esophagus normally consists of skin cells. Like all skin, the lining is not designed to be exposed to acid and other stomach contents. Long term exposure to acid causes burns in the inner lining of the esophagus (esophagitis) or scarring resulting in swallowing problems (stricture). The stomach lining, on the other hand, has specialized cells that protect the stomach lining from acid and digestive enzymes. In normal people with no reflux, at the junction of the food pipe and the stomach, skin lining meets stomach lining without any intervening abnormal tissue.
What is Barrett’s Esophagus?
In patients with long-standing reflux, the body tries to protect the junction between the esophagus and the stomach by changing the inner lining of the esophagus from skin to stomach or small bowel lining. During an endoscopy, it appears as salmon colored tissue that begins to creep up the esophagus. This abnormal lining needs to be biopsied. Under the microscope, if small bowel lining is seen, this abnormal tissue is diagnosed as Barrett’s esophagus. Barrett’s esophagus is a premalignant condition that predisposes to esophageal cancer.
What is Dysplasia?
Our present understanding is that Barrett’s esophagus has a few steps before it develops into esophageal cancer. These changes are called dysplasia. Barrett’s esophagus is normal looking small bowel lining at the junction between the esophagus and the stomach, and the cells are normal looking and are correctly oriented to each other. In other words, the architecture of the cells themselves and relationship of the cells to each other is normal looking under the microscope. However these cells have genetic mutations that predispose to cancer.
As dysplasia sets in, the cells start to appear abnormal and they do not respect the orientation with the neighboring cells. Depending on the degree of dysplasia (low-grade or high-grade), the cells can look increasingly abnormal, and the entire lining can look quite haphazard. Esophageal cancer is defined by these abnormal cells breaking through the inner lining of the esophagus and invading deeper into the wall of the esophagus and spreading to lymph glands and other organs.
What Is the Risk of Esophageal Cancer With Barrett’s Esophagus?
A recent study has answered question of the risk of progression of Barrett’s esophagus at 1.2% per year. Over a ten year period, the risk is 12%. Low-grade and high-grade dysplasia have higher rates of progression to cancer. In fact, studies have shown that patients with high-grade dysplasia have a 20% chance of having coexisting esophageal cancer.
Can Anything Be Done About Barrett’s Esophagus to Prevent Progression?
A spectrum of abnormality (low-grade and high grade dysplasia) is known before Barrett’s esophagus can become esophageal cancer. This gives us an opportunity to intervene and stop this progression. There are various treatments, including radiofrequency ablation, the most well-studied and safest treatment. Here, we use radio waves to burn the inner lining of the esophagus so that normal skin lining can develop. This treatment significantly decreases the risk of Barrett’s esophagus progressing to cancer.
Statistics About Barrett’s Esophagus:
- Barrett’s esophagus affects about 1-2 percent of adults in the United States.
- People with Barrett’s esophagus are 30 to 125 times more likely to develop cancer of the esophagus than the general population.
- The incidence of esophageal cancer has risen about six-fold in the U.S. since the 1970s. It is rising faster than breast cancer, prostate cancer, or melanoma.
- While the average age at diagnosis of Barrett’s esophagus is 50, it is difficult to determine when the disease developed pr how long a patient has been affected.
- Men develop Barrett’s esophagus twice as often as women, and caucasian men are affected more often than men of other races. Barrett’s esophagus is uncommon in children.
- Being caucasian, male, and overweight are all associated with a higher risk of cancer developing from Barrett’s esophagus.
Treatment of Barrett’s Esophagus
Barrett’s without dysplasia (the most common situation): Some evidence indicates that control of esophageal exposure to stomach contents, especially acid, may reduce the risk of Barrett’s esophagus progressing. Frequently patients with Barrett’s esophagus have a hiatal hernia with severe reflux and prominent symptoms. In these situations, an antireflux operation such as a laparoscopic hiatal hernia repair is an excellent treatment option.
For many years, Barrett’s esophagus without dysplasia has been monitored with upper GI endoscopy (EGD) and biopsies performed every 3-5 years. However, in light of recent evidence that Barrett’s esophagus progresses at a rate of 1.2% per year, this 3-5 year interval may be shortened in the future.
Although evidence is currently lacking (2012), many specialists think the best treatment for Barrett’s esophagus without dysplasia is to eradicate it before it has the chance to develop into dysplasia. This is analogous to removing any colon polyp that could develop into cancer during colonoscopy. Fortunately, minimally invasive endoscopic procedures, such as Radiofrequency Ablation (RFA with BarrX, see below), are now available to eradicate Barrett’s and are being used in select instances before dysplasia develops.
Treatment of Barrett’s esophagus with dysplasia: Dysplastic Barrett’s esophagus can be effectively treated using minimally invasive endoscopic techniques (no incisions). Radiofrequency ablation using the BarrX device and endoscopic mucosal resection (in more advanced dysplasia) are the two primary modalities for treating dysplastic Barrett’s.
Once the bad lining is eradicated, if reflux is controlled, the new lining that develops is normal skin lining.
Radiofrequency Ablation (RFA) with BarrX
Radiofrequency ablation (RFA) consists of device that is attached to the end of an endoscope that is placed into the esophagus through the mouth. The device delivers heat energy to the diseased lining of the esophagus. The procedure is performed under intravenous sedation as an outpatient. A number of studies have demonstrated that RFA is safe and effective, resulting in a high rate of complete eradication of dysplastic Barrett’s esophagus. This stops progression to higher grades of dysplasia and esophageal cancer. Commonly, 2-4 treatments are required over a period of a few months to achieve complete eradication of the Barrett’s esophagus changes. A recent study showed excellent long term success with very low recurrence rates after ablation of Barrett’s.
Once the esophageal lining is treated and the Barrett’s is gone, reflux needs to be treated or Barrett’s esophagus will likely return. This is done with either lifelong proton-pump inhibitor medication to reduce esophageal exposure to acid, or antireflux procedures to reduce esophageal exposure to all gastric contents (e.g. laparoscopic hiatal hernia repair). Current recommendations include that surveillance endoscopy still be performed.
Endoscopic therapies are performed at specialty centers by physicians with expertise in these procedures.
Endoscopic Mucosal Resection (EMR)
For areas within dysplastic Barrett’s esophagus lining which are raised or depressed and more suspicious for cancer, a method called endoscopic mucosal resection (EMR) may be used to remove the damaged lining. This is a new organ sparing technique as most of these patients historically have undergone surgical removal of the esophagus. The wall of the esophagus can be compared to a multi-layer cake. As long as the cancer or precancer is in the frosting or the superficial layers of the cake, those layers can be removed without removing the esophagus. As the cancer invades into the deeper layers of the cake, the only chance of cure is removing the entire esophagus, which is an extremely morbid surgery.
Esophagectomy – Surgical Removal of the Esophagus
Once esophageal cancer invades the deeper layers of the wall of the esophagus, the only chance of cure is to remove the entire esophagus. The surgery that involves removing the esophagus and top part of the stomach is called an esophagectomy. A portion of the stomach is then pulled up into the chest or neck and connected to the remaining normal portion of the esophagus, creating a “new” esophagus. Esophagectomy is a major operation and has significant risks.