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 cannot. As a result, when the 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-reflex surgery. While prescription medications help suppress acid production they do not prevent the 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. The surgery requires general anesthesia multiple incisions and a recovery period lasting several days. The newer treatments for GERD include the Stretta procedure, TIF (Transoral Incisionless Fundoplication) and the Lynx procedure.
Barrett’s esophagus is a precancerous condition that developed 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 with intestinal metaplasia or Barrett’s esophagus.
The 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 guide a long thin to 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 call a biopsy. The biopsy will be examined by a pathologist 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, the Barrett’s cells may develop abnormal changes called dysplasia. Over several years, the dysplasia may progress into 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. If minor concerning changes are noted by the pathologist under the microscope, the diagnosis of low-grade dysplasia is made. If major concerning changes occur, the diagnosis of high-grade dysplasia is made. High-grade dysplasia is very similar to carcinoma in situ or superficial cancer. While high-grade dysplasia has a high change of progressing into cancer, carcinoma in situ will eventually developing to invasive esophageal cancer if not treated.
Patients with Barrett’s esophagus are at higher risk than the general population for developing esophageal cancer. The standard of care for Barrett’s patients has been endoscopic biopsy surveillance to detect dysplasia or early cancer.
A question that is frequently asked is why does one patient with Barrett’s esophagus progress to cancer while another patient does not. The answer is felt to lie in the genes of the esophagus that can change over time predisposing one to further genetic changes and eventually into cancer. By finding these abnormal genes early on, we may be able to intervene prior to the onset of dysplasia or cancer thus preventing its development.
Most tests rely on a molecular biology technique of endoscopic biopsy samples. Extensive research is presently occurring to help find the right gene or set of genes that will predict with a high degree of certainly who will develop dysplasia and who will not.
The treatment options of Barrett’s esophagus depends on the grade of dysplasia. If no dysplasia is present, most authorities do not recommend treatment although there are certain circumstances were treatment may be advised. If low-grade dysplasia is seen and reproduced, many authorities recommend endoscopic treatment although they are times when a period of close observation is felt best. If high-grade dysplasia is present, most authorities would recommend some type of treatment which would include endoscopic procedures or surgery. If cancer is present, a much higher degree of concern exits and the best options for therapy will be based on a whole variety of information including patient age and health as well as endoscopic, radiologic and pathologic assessment of the tumor.
The options for endoscopic treatment include endoscopic mucosal resection (EMR), radiofrequency ablation, cryotherapy, contact ablation or photodynamic therapy (PDT). These will be discussed below.
Photodynamic therapy is a treatment that uses a combination of a photosensitizer (a light activated medication) called Photofrin and laser light to destroy abnormal cells. PDT patients are injected with Photofrin to render their tissue extremely sensitive to laser light. The lesion is then illuminated with a laser light of proper power and wave length. The interaction of laser light and a Photofrin causes a chemical reaction killing the abnormal cells. 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 is esophageal scarring and narrowing of the lumen. This occurs in approximately 20% of patients and is managed by dilation with the endoscope.
While PDT was the first original endoscopic treatment for patients with Barrett’s and high grade dysplasia, its risks now limit its use to tumor reduction in those with advanced esophageal cancer or as an alternative to esophagectomy (the surgical removal of the esophagus) for patients with early cancer.
Radiofrequency ablation, also commonly called BARRX or the Halo procedure, is a new endoscopic technique used for the treatment of Barrett’s esophagus. It is a technique that allows radiofrequency energy to be directed to the abnormal cells in an automated and controlled fashion limiting its tissue injury to the abnormal cells and preventing deeper normal tissue involvement. The ablation may be repeated over time until the entire area of abnormal cells are resolved. The entire procedure is performed as an outpatient under sedation provided by an anesthesiologist. Typically the procedure takes about 15-20 minutes. Post treatment, patients may experience mild pain and/or nausea for several days. These symptoms are easily controlled with medications. Patients are advised to adjust their diet for 24-hour hours after treatment followed by a soft food diet for several days afterwards. About 3 months after the treatment, a repeat endoscopy is performed to evaluate the effectiveness of the treatment and perform repeat treatments if needed. Effective acid control with a proton pump inhibitor is crucial during the healing process to assist with healing and prevent Barrett’s return.
RFA can be delivered through a variety of catheters. Short segments or small patches of abnormal cells can be treated with a HALO 90 or Halo 60 device which is attached to the end of the endoscope and are about the size of a postage stamp. Even smaller patches may be treated by a through the scope method with Channel RFA. Larger segments are treated with a balloon technique called a HALO 360 Express ablation catheter which can treat up to 4cm at a time.
Endoscopic mucosal resection is an endoscopic procedure used to remove small nodules, early cancers or segments of Barrett’s esophagus that are resistant to simple treatment. The Center utilizes both cap assisted and ligation assisted techniques. Using the cap assisted technique, a nodule is removed by endoscopically placing a tiny rubber band around the nodule forming a pseudo-polyp making it easier to grasp and remove with a cutting device. The procedure is performed during routine endoscopy with sedation. An advantage of the EMR technique is that the nodule can be removed in total giving the pathologist a whole specimen to evaluate rather than just a small biopsy.
Endoscopic thermal ablation is an outpatient procedure that uses both laser and non-laser sources to thermally ablate the Barrett’s esophagus. The Center provides an Nd:YAG laser contact probe to ablate tiny areas of Barrett’s that are not suitable for radiofrequency ablation or cryoablation. It is frequently used during routine follow-up procedures and can be performed with simple sedation. Bipolar and monopolar electrocoagulation techniques are also available.
Cryotherapy is a new technique that uses the extreme cold to destroy the Barrett’s esophagus. Liquid nitrogen, CO2 and nitrous oxide are among available sources of extreme cold. The Center uses the through-the-scope Cryoballoon Focal Ablation system that consists of a battery powered handle, a balloon catheter and a cartridge that stores the liquid nitrous oxide. The system is programmed to deliver a preset amount of fluid inside the balloon after it is positioned within the Barrett segment during a routine endoscopy. The cryotherapy is maintained within the balloon catheter eliminating the need for venting of the gas from the esophagus and stomach. The system delivers more accurate treatment and is safer to apply in an outpatient procedure.
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.