1. Best Treatment for Barrett’s is Surgery
Bill Richards, MD FACS
Professor and Chair Surgery
University of South Alabama
College of Medicine

2. Barrett’s = Intestinal Metaplasia
Metaplasia = change in cell-type
Squamous to specialized intestinal cells
First described by Norman Barrett in 1950
Adaptive mechanism to injury

3. Metaplasia (no dysplasia)
Disease Course
Progression usually occurs but regression sometimes seen
Duration of progression variable
Metaplasia (no dysplasia)
Low-Grade Dysplasia
High-Grade
Dysplasia
Adenocarcinoma
Ginsberg et al. In: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 7th ed. 2002:

4. Risk of Adenocarcinoma in Barrett’s Esophagus
% per year
5-10% lifetime

5. Current Management of Barrett’s Patients*
Intestinal Metaplasia Surveillance (2-3 yrs)
Low grade dysplasia Surveillance (6-12 mo)
High grade dysplasia Surveillance (3 mo) vs. Esophagectomy
This is how patients are managed right now - Watch and Wait
Most patients are just watched
As patient progresses to Low Grade Dysplasia, keep watching
But once the dysplasia goes to High Grade, the choices have become very limited:
Maybe Photodynamic Therapy or Esophagectomy
Patients have to make a choice, They can be watched more often, or have the esophagus taken out.
Then, if the diagnosis progresses to adenocarcinoma, the only choice is to take the esophagus out.
Adenocarcinoma Esophagectomy vs Palliative Care
* May Differ per Institution

6. One Outcome of Surveillance
Esophageal Adenocarcinoma
Baseline Barrett’s Esophagus

7. Mixed Reflux of Gastric and Duodenal Juices is more Harmful to the Esophagus than Gastric Juice Alone Kauer WK et al Ann Surg 222:
Prevalence of esophageal bilirubin exposure

8. Bile Reflux Induces Adenocarcinoma of the Esophagus
Ireland et al Ann Surg September; 224(3): 358–371.

9. Antireflux Surgery
1976 Donahue and Bombeck defined a technique of "floppy" Nissen fundoplication (FNF) that prevented experimental pathologic reflux without preventing gaseous eructations or vomiting (normal reflux) when appropriate

10. LES Pressure Returns to Normal After Laparoscopic Fundoplication
Peters JH et al. Ann Surg 1998;228:40-50.

11. 24 Hour pH Studies after Laparoscopic Fundoplication
Author
# patients
pH Negative
Follow-up
(months)
Hinder
(87%)
3-12
Hunter
(91%) 12
Watson 3
Peters
(93%) 21

12. Does Nissen reduce NonAcid Reflux?
8 patients with Barrett’s
24 hour pH and nonacid relfux
- before (on omeprazole 20 mg BID)
- after laparoscopic Nissen fundoplication

13. Acid
Episodes
Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

14. P=0.001
Non-Acid
Episodes
Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line)

15. Conclusions: Patients with Barrett’s esophagus
Nissen eliminates acid and non-acid reflux
PPI’s fail to eliminate acid reflux in 33-50%
PPI’s do not reduce non-acid reflux

16. Ortiz et al Br J Surg. 1996 Feb;83(2):274-8
Conservative treatment versus antireflux surgery in Barrett's oesophagus: long-term results of a prospective study.
Ortiz et al Br J Surg Feb;83(2):274-8

17. Regression of Barrett’s after Fundoplication
STUDY
# PATIENTS short segment
% REGRESSION
U WASHINGTON
Ann Surg October; 238(4): 458–466 61
56%
USC
Ann Surg October; 234(4): 532–539 26
14%

18. Should We Treat Barrett’s?
Standard of care = removal of pre-cancerous lesions
colon polyps (7 M annual U.S. colonoscopies)
cervical dysplasia
breast masses
dermatologic lesions (moles, actinic keratoses)
In the rest of the medical world, we take out pre-cancerous lesions. But for Barrett’s esophagus, what do we do? Just watch and wait.

19. Techniques for Mucosal Ablation
Mechanical
Endoscopic mucosal resection (EMR)
Photochemical
Photodynamic Therapy
Thermal
Argon plasma coagulation
Multi-polar coagulation
Bipolar energy
Lasers: Argon, Nd: YAG, KTP-YAG
Low-flow cryoablation
Techniques for Mucosal Ablation
The methods of mucosal ablation can be divided into three basic categories. The mechanical is endoscopic mucosal resection which can usually is applied with cautery. It involves making sessile lesions in the esophagus more polypoid through either injection of a bulking agent such as saline, methylcellulose, or hypertonic glucose or applying suction to the lesion. Thermal methods cauterize a mucosal lesions and can involve multiple types of thermal energy including laser therapy. Photodynamic therapy is a combination therapy in which a photosensitizing drug must be given first to allow its accumulation within the mucosa. The drug can then be activated by light which produces the photodynamic effect which causes cell death.

20. Overall Conclusions
Balloon-based ablation can eliminate all histological evidence of IM after 1-2 treatments
No safety issues
LGD and HGD trials underway
Promising early results
Early data shows complete elimination of dysplasia after one treatment as possible

21. Conclusion This is an exciting, rapidly growing field.
Currently, there is no ideal ablative modality.
Patients should be treated with very close followup.
Multimodal ablative therapy may have significant role.

22. Summary Barrett’s associated with Non Acid and Acid Reflux
Non acid and acid reflux can cause esophageal cancer in experimental animals

23. Summary Nissen significantly reduces acid and non acid reflux
PPI’s reduce acid reflux only and normalize 50-80% of patients

24. Summary
There is no proof that Nissen fundoplication can prevent progression to cancer.
But Nissen fundoplication is the only modality that can reduce both acid and non acid reflux and has been shown to reverse Short Segment Barrett’s