Treatment

Aim

The aim of treatment is to remove abnormal cells, allowing the lining of the oesophagus to grow back with normal cells. The process of removing dysplastic Barrett's should be considered a treatment journey, with several individual treatments and assessments being used together to do our best to get rid of the Barrett's and prevent cancer, or detect and treat cancer at a very early stage. This usually involves a number of upper GI endoscopic treatments which are summarised here and are explained in more detail below.

• Any nodules or lumpy areas are removed in 'chunks'. This is called an Endoscopic Mucosal Resection (EMR).
• Other large areas of dysplasia are destroyed using a special energy device called Radio Frequency Ablation (RFA). This allows long areas of dysplastic Barrett's oesophagus to be treated.
• Small residual areas of dysplasia or Barrett's oesophagus are destroyed with a smaller device. This is called Argon Plasma Coagulation (APC).

After getting rid of the dysplastic Barrett's, further endoscopies are performed at regular intervals to check for any re-growth of abnormal cells.

Treatment plan

The overall treatment plan can be broken down into different phases, called the treatment cycle, the follow-up cycle, and surveillance. These are shown, along with the associated procedures, in figure 1.

Figure 1. Dysplastic Barrett's treatment, follow-up and surveillance. OGD - upper GI endoscopy.

Endoscopic Mucosal Resection (EMR)

The wall of the oesophagus has several layers, as shown in Figure 2.

Figure 2. Layers of the wall of the oesophagus.

Dysplasia and early cancers are found and limited to the innermost layer, which is called the mucosa. The mucosa rests on a layer of connective tissue that carries blood vessels and nerves, which separates it from the muscle layers of the oesophagus. Endoscopic mucosal resection (see figures 3-5) involves the removal of 1-2cm discs of mucosa using an endoscope. Because the endoscope is inserted and removed several times during the procedure and it takes longer than a regular endoscopy, we currently perform this procedure under general anaesthetic in an operating theatre.

Figure 3. Endoscopic mucosal resection procedure.

Figure 4. Abnormal area of Barrett's to be removed with EMR (seen using acetic acid chromoendoscopy). Source: UHBW NHS Foundation Trust.

Figure 5. Area shown in figure 4 after removal by EMR. Source: UHBW NHS Foundation Trust.

The first step of the procedure is to check that there is no sign of cancer invading the muscle layers. If this is the case, it is not possible to remove the abnormal cells / cancer with an endoscope. Furthermore, if there is a cancer that is advanced enough that it invades a deeper layer; the risk of it spreading to lymph glands nearby is over 50%. This would mean that in 1 of 2 patients, the treatment would not be curative. To check if there is cancer invading the muscle, we inject a blue solution under the mucosa to "lift" it away from the muscle. This not only confirms that there is no attachment between the mucosa and the muscle, but makes it safer to remove the mucosa.

As with any endoscopy, there are some risks. These include making a hole in the oesophagus (perforation), or making the oesophagus bleed. Bleeding is often minor and can be stopped at the time of your procedure. After the procedure, there is a small risk of scarring developing at the EMR site causing a narrowing that makes it difficult to eat and drink normally. This may occur some weeks after the procedure, but is rare. More information about these and other risks are discussed in the EMR-specific booklet you will be given on the day of your procedure, and will be discussed with you on the day of your clinic appointment.

If you have had an EMR of a nodule in your Barrett's oesophagus, the next step is to treat the rest of the Barrett's. This is done using a technique called radiofrequency ablation or HALO. This is scheduled for 8 weeks after your EMR to allow the gullet to heal. For patients having EMR that completely removes the Barrett's, a standard endoscopy under sedation or with throat spray is done to check the EMR site has healed, again 8 weeks later.

Radio Frequency Ablation (RFA)

Radio frequency ablation is a treatment, which uses radio frequency energy, a type of radiation similar to that used in mobile phones, to produce a heating effect on the Barrett's cells to destroy them (see figure 4). The treatment is delivered during an endoscopy procedure under general anaesthetic and patients can go home the same day.  A thin probe is passed through the endoscope which has a balloon at the end, wrapped in wires. Energy is sent to the wires which heats them up. This burns only the Barrett's cells in the affected part of the oesophagus. We use a device that provides a burn through 360 degrees to the circumference of the oesophagus.

Figure 4. Radiofrequency ablation device and diagram illustrating its use in the lower oesophagus.

In some cases when the Barrett's is affecting a long stretch of the gullet, we may decide to treat the Barrett's in 2 procedures to minimise the risks.

As with EMR, this is a safe procedure but there are some risks that you need to understand. These risks include making a hole in the oesophagus (perforation) and bleeding. After the procedure, there is a risk of scarring developing as the oesophagus heals, causing a narrowing that makes it difficult to eat and drink normally. This may occur some weeks after the procedure. More information about the risks of the procedure will be discussed with you in clinic and on the day of your procedure.

After we have treated the Barrett's, we will schedule a standard endoscopy under sedation or throat spray 8 weeks after the RFA to check there is no remaining Barrett's. If there is, it can be treated with a device called Argon Plasma Coagulation (APC), which is described below.

Argon Plasma Coagulation (APC)

Argon Plasma Coagulationis a treatment that uses a jet of argon gas, together with an electric current to burn away small patches of Barrett's cells in the oesophagus. The treatment is carried out during an endoscopy and you will be given a sedative to make you slightly sleepy during the procedure. The procedure takes about 20 minutes and patients can go home the same day.

Argon Plasma Coagulation is repeated every 8 weeks until any remaining areas of Barrett's are destroyed. Some patients do not need APC treatment or just one session, while others may need 2 or more sessions. Once you have had an endoscopy showing complete destruction of your Barrett's, we can move on to surveillance endoscopy.

Surveillance

After treatment for Barrett's oesophagus with dysplasia you will be advised to have an upper GI endoscopy and biopsies at regular intervals to monitor the treated area. This is called surveillance. Surveillance begins once we have confirmed that all the Barrett's has been destroyed. The first two endoscopies are done at 6 monthly intervals after the Barrett's is confirmed to have been destroyed for 1 year. Then you will have annual endoscopies until 5 years after completing treatment.

These endoscopies are done at the A414 Queens Day Unit in Bristol by our team. This is because we have the necessary expertise in treating this condition, we have access to your previous treatment records, and we know which area to biopsy at each endoscopy. If Barrett's returns, we have pathways and procedures in place to effectively deal with that. We appreciate that for some patients this may involve a lot of travelling. Please feel free to raise this issue with a member of our team, including your local Clinical Nurse Specialist, if you are finding it difficult to make the journey. It may be possible to do some endoscopies in South Bristol, Bath or Weston by members of our surgical team if these would be more convenient.

After 5 years, you will be discharged back to the care of your GP. You will not need any further Barrett's surveillance endoscopies.

Anti-acid medication

People with dysplastic Barrett's oesophagus are advised to take regular anti-acid medication, even if you do not have symptoms of acid reflux.

The most commonly used drugs to lower acid levels are called Proton Pump Inhibitors (PPIs). These include omeprazole and lansoprazole, amongst others. These types of drugs are some of the most widely used in the NHS because symptoms of acid reflux are so common.

Lifestyle changes

Being overweight or obese is associated with reflux, Barrett's oesophagus and oesophageal cancer. It is therefore important to lose weight if you are overweight or obese.

Smoking cigarettes and drinking alcohol are also associated with acid reflux. Stopping smoking and avoiding alcohol will help control any symptoms and reduce the level of acid going back up into the oesophagus.

Adopting these changes will also have an important beneficial effect on your overall health.