What is Gastroesophageal reflux disease (GERD)? Back to Top
Gastroesophageal reflux disease (GERD) is the chronic backflow of stomach contents into the esophagus. While the tissue lining of the stomach is able to handle digestive contents such as acid, the lining of the esophagus is not. As a result, when stomach contents back up into the esophagus, it can cause a burning sensation commonly referred to as heartburn, the major symptom of GERD. In addition to heartburn, other symptoms associated with GERD include regurgitation, chest pain, hoarseness, wheezing, and chronic cough. A major complication of GERD is Barrett's esophagus, a premalignant condition of the esophagus.
More than 15 million Americans suffer from daily heartburn. Until recently, treatment options for GERD have been limited to chronic drug therapy or anti-reflux surgery. While prescription medications help suppress acid production, they do not prevent the physical backflow of gastric contents into the esophagus. Anti-reflux surgery is effective in addressing the root cause of GERD by correcting the weakened valve mechanism; however, such surgery requires general anesthesia, multiple incisions and a recovery period lasting several days. An endoscopic procedure called full thickness plication is now available that can reduce or eliminate the need for prescription medication in most patients.
What is Barrett's Esophagus? Back to Top
Barrett's esophagus is a precancerous condition that develops in approximately 10% of patients who have gastroesophageal reflux disease (GERD). In Barrett's esophagus, the normal cells that line the esophagus, called squamous cells, turn into a type of cell called specialized columnar cells or Barrett's esophagus.
Diagnosis of Barrett's esophagus involves an endoscopy procedure to look at the lining of the esophagus and biopsies to examine samples of suspect tissue. To do an endoscopy, your doctor gently guides a long, thin tube called an endoscope through the mouth and into the esophagus. The endoscope contains a camera and light that allows the doctor to see the lining of the esophagus and to remove a small tissue sample, called a biopsy. The biopsy will be examined in a lab to see whether the normal squamous cells have been replaced with Barrett's cells.
Once the cells in the lining of the esophagus have turned into Barrett's cells, they will not revert back to normal. In about 5% of patients, Barrett's cells may develop abnormal changes called dysplasia. Over several years, the dysplasia may progress to adenocarcinoma (cancer) of esophagus. Patients with Barrett's esophagus are 30-40 times more likely to develop esophageal cancer than the normal population.
There are different grades of dysplasia. Most patients will not develop any dysplasia within their Barrett's esophagus. Barrett's esophagus without dysplasia is also called intestinal metaplasia. In some patients, the Barrett's cells may progress to low grade dysplasia which is worse than intestinal metaplasia. Barrett's cells may become more dysplastic and develop into high grade dysplasia. High grade dysplasia is very similar to carcinoma in situ, or superficial cancer. Carcinoma in situ will eventually develop into invasive esophageal cancer if not treated.
Does smoking increase your risk of cancer? Back to Top
If you have Barrett’s esophagus and smoke, you are at a much higher risk of getting esophageal cancer. In a recent study of 3167 Barrett’s patients, smoking tobacco increased the risk of progression to cancer and high grade dysplasia by a factor of two. This is another important reason to stop smoking!
What are the treatment options for Barrett's esophagus? Back to Top
Treatment options for Barrett's patients depend on the grade of dysplasia. The Center provides a variety of treatment options for patients with or without dysplasia. Until recently, the only treatment for patients with high grade dysplasia was esophagectomy, or surgical removal of the esophagus. The Center utilizes several outpatient endoscopic procedures for treatment of Barrett's esophagus to include Photodynamic Therapy (PDT), Radiofrequency ablation (BÂRRX procedure) using HALO360, HALO90, HALO60 and HALO Ultra, Thermal laser ablation and Endoscopic Mucosal Resection (EMR). An option for patients who do not have any dysplasia (have intestinal metaplasia) is observation with regular endoscopy and biopsies. If dysplasia is detected, treatment option may be offered.
Patients who have nodular disease (small lumps) within their Barrett's esophagus, may be candidates for a procedure called Endoscopic Mucosal Resection (EMR) followed by either PDT, BARRX, laser ablation or additional EMR. An endoscopic ultrasound (EUS) of the nodular area is sometimes performed to determine whether endoscopic ablation procedures are appropriate for the patient.
What is Photodynamic Therapy (PDT)? Back to Top
- How Does Photodynamic Therapy Work?
Photodynamic therapy (PDT) is a treatment that uses a combination of photosensitizer (a light-activated drug) and laser light to destroy abnormal cells. PDT patients are injected with a photosensitizer to render their tissue extremely sensitive to laser light. The lesion is then illuminated with a laser light of proper power and wavelength (color). The interaction of laser light and the photosensitizer causes a chemical reaction, killing the abnormal cells. Photodynamic therapy can be used to reduce the tumor mass in patients with advanced esophageal cancer. However, a primary use of PDT is as an alternative to esophagectomy (the surgical removal of the esophagus) for patients with high-grade dysplasia and early cancer in Barrett's esophagus.
- Photodymanic Therapy For Barrett's Esophagus
Until recently, the standard treatment for patients with high-grade dysplasia was esophagectomy. This is an invasive surgical procedure associated with a 3.4%-19% mortality rate and significant morbidity. Typically, patients require several weeks of hospitalization and full recovery may take months.
Photodynamic therapy is an alternative outpatient endoscopic procedure for patients with high-grade dysplasia in Barrett's esophagus. During PDT, patients are injected with a photosensitizer (Photofrin). Laser light is delivered two to three days later using a specially designed light delivery balloon. A side effect of Photofrin is light sensitivity. Patients must avoid direct exposure to sunlight and bright lights for about 4-6 weeks. The primary complication of PDT for Barrett's esophagus is esophageal stricture, scarring and narrowing of the esophageal lumen. This occurs in approximately 20% of patients and is managed by dilation. We are currently working on reducing or eliminating the stricture formation.
The PDT balloon, which is necessary for effective delivery of laser light to Barrett's esophagus, was clinically developed and tested at the Laser Center, where all the treatments are performed. The Laser Center is considered a world leader in the use of balloon-PDT for Barrett's esophagus.
What is BÂRRX procedure for Barrett's esophagus? Back to Top
BÂRRX procedure ( Radiofrequency Ablation) is a new endoscopic technique used for treatment of patients with Barrett's esophagus with or without dysplasia. Barrett's esophagus without dysplasia is also called intestinal metaplasia.
During the procedure, the exact diameter of the esophagus is measured using an automated dilation catheter. Then using a proper sized ablation catheter called HALO360, radiofrequency (RF) energy is delivered to a 3 cm circumferential segment of the Barrett's esophagus. Delivery of energy is automated and takes a few seconds. The energy is adjusted to allow a limited depth of injury to destroy the Barrett's cells without destroying the normal tissue in the deeper layer. The ablation may be repeated until the entire length of the Barrett's segment is treated.
Short segments or small patches of Barrett's esophagus may be treated using probes called HALO90 or HALO60. These probes are the size of a small postage stamp. The probe is attached to the end of the endoscope before the endoscopy procedure. The endoscope/probe is passed into the esophagus where the Barrett's esophagus is visualized. The RF energy is then delivered to the Barrett's mucosa. Longer segments may be treated using the HALO Ultra probe.
Following the procedure, patients may experience mild pain and/or nausea for several days. These symptoms are easily controlled with medications. Patients must stop taking all blood thinners several days before and after the procedure (number of days depends on the type of blood thinner). Patients are advised to stay on clear liquids for 24 hours followed by a soft food diet for several days after the procedure.
The procedure is performed on an outpatient basis under moderate sedation or propofol anesthesia. Typically, the procedure takes about 15-20 minutes and is well tolerated by patients.
About three months after the treatment, patients need to have an endoscopy with biopsies performed to evaluate the effectiveness of the treatment. Several additional follow-up endoscopies are recommended. In a clinical study, 75% of patients treated were clear of their Barrett's esophagus at 6 months. In the remaining 25% of patients, greater than 90% of Barrett's tissue was removed. Effective proton pump inhibitor (PPI) therapy is critical to control the acid reflux during the healing process.
HALO 90 Probe
|HALO 360 Balloon
What is Endoscopic Mucosal Resection (EMR)? Back to Top
Endoscopic Mucosal Resection (EMR) is a procedure that is available for removal of small nodules within the Barrett's segment. These nodules are typically a sign of disease progression and should be removed before they become invasive cancer. Using Duette® Multi-Band Mucosectomy device, the nodules are removed by endoscopically placing a tiny rubber band around the nodule, making it easier to grasp. Then, an electrosurgical snare is used to cut and remove the nodule. EMR may also be used for treatment of small areas non-nodular Barrett's esophagus with dyspalsia.
EMR is performed during a routine endoscopy under moderate sedation. Several weeks after the site of EMR has healed, patients may receive PDT, BARRX, laser ablation, cryotherapy, or additional EMR, depending on the results of the pathology. An advantage of EMR technique is that not only the nodule is removed, a pathological examination of the nodule is also obtained, which helps in determining the depth of abnormal cells. This helps in staging the progression of disease in Barrett's patients.
What is endoscopic thermal ablation? Back to Top
Endoscopic thermal ablation is an outpatient procedure that uses a laser (or non laser) source to thermally burn Barrett's tissue. The Center provides an Nd:YAG laser with contact probe to accurately treat small areas of Barrett's esophagus that are not suitable for photodynamic therapy, BÂRRX or cryotherapy. Nd:YAG laser is also used during the follow-up endoscopy of patients who return with small islands of Barrett's mucosa. Bipolar or monopolar electrocoagulation techniques are also available and may be used at the discretion of physician.
What is Bravo pH Monitoring? Back to Top
Accurate diagnosis of gastroesophageal reflux disease (GERD) is critical before an effective treatment is initiated.
The Center uses the world's first catheter-free test for GERD diagnosis called the Bravo® pH Monitoring System.
Using the Bravo system, a miniature pH capsule, approximately the size of a gel cap, is temporarily attached to the wall of your esophagus during a routine endoscopy.
The capsule measures pH levels in the esophagus continuously for 48 hours and transmits the data wirelessly to a portable receiver worn on the patient's waistband. There's no cumbersome catheter or visible wires. After the capsule stops transmitting data, the patient returns the receiver to the Laser Center. The pH data is then retrieved from the receiver. Several days after completion of the study, the capsule spontaneously sloughs off the wall of the esophagus and is passed through the gastrointestinal tract.
These pH measurements allow the physician to effectively evaluate the acid reflux symptoms and recommend treatment options. The Bravo pH monitoring system allows patients to continue normal activities during the test period, so the patient can eat and drink normally, bathe, sleep comfortably, and maintain daily life.
Patients are restricted from undergoing an MRI (Magnetic Resonance Imaging) for thirty days after the Bravo procedure.