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Barrett's Esophagus

Barrett’s esophagus is a condition in which the normal cells lining the esophagus transform into an intestinal-cell type as a result of chronic injury from gastroesophageal reflux disease. The importance of Barrett’s esophagus is that it is considered a pre-cancerous condition, and it is the origin of esophageal adenocarcinoma. It is estimated that up to 20% of patients with reflux disease harbor these changes, and screening endoscopy is recommended for this reason. There is a risk of approximately 0.5% per year of untreated Barrett’s esophagus developing into cancer.

Our Approach

  • One of the largest experiences in the diagnosis, surveillance, and treatment of Barrett’s esophagus in the country
  • Dedicated esophageal diagnostic lab run by USC thoracic surgeons with integrated esophageal function testing and endoscopy
  • Availability of endoscopic ablation and resection techniques to allow for esophageal preservation for high grade dysplasia and intramucosal cancer
  • Tailoring of the antireflux operation to the patient’s disease and physiology
  • Extensive experience in re-operative procedures and remedial operations for GERD
  • High-volume referral center for Barrett’s esophagus with knowledgeable thoracic surgeons, nurses, and staff

Mechanism of Disease

As gastric contents reflux into the esophagus over time, the normal squamous cells of the esophagus are injured and slough away. In some individuals, the esophagus regenerates its lining with unique intestinal cells that are normally not present in the esophagus or stomach in a process known as intestinal metaplasia. It is thought that chronic reflux disease and the presence of bile are critical determinants of the formation of Barrett’s esophagus. These intestinal cells are pre-cancerous. With further injury and genetic alterations, dysplasia occurs, and ultimately may develop into esophageal adenocarcinoma. [FIGURE]

Diagnosis

Patients who have Barrett’s universally have GERD, and usually have symptoms of heartburn, regurgitation, and difficulty swallowing. Barrett’s esophagus is diagnosed with endoscopy and biopsies. When these abnormal intestinal cells replace the normal esophagus, there are some visible clues to indicate its presence, but biopsies are definitive. In some cases, the endoscopic changes are subtle and biopsies will pick up microscopic evidence that intestinal metaplasia has occurred. USC benefits from having on its staff a world expert pathologist in reflux disease and Barrett’s esophagus, Dr. Para Chandrasoma. Due to the challenges in interpreting slides of Barrett’s esophagus, especially with dysplasia, slides from around the country are sent to USC for review and diagnosis.

Treatment Options

The main treatment of Barrett’s esophagus without dysplasia is to control the reflux disease. Typically, patients with Barrett’s have severe reflux with prominent symptoms, and often have a hiatal hernia as well. In these situations, an antireflux operation such as a laparoscopic Nissen fundoplication is an excellent treatment option. When Barrett’s develops into dysplasia, a step closer to cancer formation, the abnormal lining of the esophagus may be burned away or ablated using radiofrequency ablation with a technology known as BarrX®. Another technology used to ablate Barrett’s esophagus is with cryoablation, or the use of freezing technology to burn away the lining of the esophagus. [FIGURE]

Regardless of type of treatment, whether it is antireflux surgery alone or combined with radiofrequency ablation, surveillance of the Barrett’s esophagus is critical. When no dysplasia is present, USC thoracic surgeons perform annual surveillance endoscopy with biopsies. This frequency may be shortened in the setting of dysplasia.

Treatment Outcomes

Due to the relatively low incidence of esophageal cancer, it has been difficult to prove definitively that antireflux surgery decreases the possibility of cancer arising from Barrett’s esophagus. Nevertheless, indirect observations indicate that this is likely the case due to the protective effect of antireflux surgery. In many patients with a short area of Barrett’s esophagus, antireflux surgery has been shown to reverse these changes and the intestinal cells sometimes go away. Moreover, our research into the genetic changes of Barrett’s esophagus indicate many of the genetic alterations in Barrett’ esophagus return to more normal levels following antireflux surgery. All of these effects likely contribute to a lower risk of esophageal adenocarcinoma in patients with Barrett’s esophagus who undergo an antireflux operation.

Radiofrequency ablation (BarrX®) or cryoablation has been a major advance in the treatment of Barrett’s esophagus with severe dysplasia. It has allowed the preservation of the esophagus in many patients who would have undergone an esophagectomy in the past.

Future Research

 

 

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