Burning Away Barrett's Esophagus -- In-Depth Doctor's Interview
Dr. John Carroll, Assistant Professor of Medicine in the Division of Gastroenterology at Georgetown University in Washington, D.C., talks about a new radiofrequency procedure used to treat Barrett’s Esophagus.
What is Barrett’s Esophagus?
Dr. John Carroll: Barrett’s is scar tissue in the esophagus once it’s been damaged, typically from stomach acid, and really, it’s a protective mechanism -- it’s almost like getting a callus. In some people, when the cells have been injured by acid, they take on a change to protect themselves. That in and of itself is harmless, but like with many other cells in the body, once they’ve been changed and altered, there are sort of one or two gene defects away from changing further and going down the cancer route. That’s where the issue of Barrett’s comes in.
How common is Barrett’s Esophagus?
Dr. Carroll: The main data is in people with heartburn -- about 10 to 50 percent of them will have Barrett’s. The trouble is, there’s a bigger, unknown element of people without symptoms. About half of Barrett’s patients didn’t even have heartburn symptoms to begin with, so the typical alarm sign of indigestion, many people for whatever reason don’t feel. Because of this, the true number isn’t known, but we know that if you look at just people with symptoms, you are probably only capturing about half of those people who really have Barrett’s esophagus. That’s why it gets much more difficult to really identify those people and estimate the true number.
How do you treat Barrett’s Esophagus?
Dr. Carroll: Historically, the approach has been to watch it. Most people with it do not develop cancer -- it’s a relative minority of people that do develop the progressive cancer changes that then need full blown treatment. The trouble is for those people that get it, it’s a major, major cancer. In the last 10 or 15 years, there have been all sorts of ways to try to remove the Barrett’s, but it’s been pretty much unsuccessful. There have been some sort of light laser treatments in the last 10 years or so that have been effective in burning off that layer, but they’ve been fairly involved and they come with risks and some complications, so it’s been reserved for just those select people that have developed those intermediate, pre-cancer changes. For the most part, up until recently, it’s been really just a watch and wait approach, and trying to follow patients closely. For those patients that do develop the pre-cancerous changes, it’s been operating on them right away, but that’s a major, major operation.
What is the traditional operation for patients who develop cancer?
Dr. Carroll: Although the area can be small -- it may be only one or two inches long -- because of the blood supply and the anatomy, you need to take out a much bigger section. It’s really taking out the lower junction where the esophagus meets the stomach, kind of right in the middle of the abdomen, between where the chest and abdomen meet, but having to go a little bit lower and quite a bit higher, again, because of the anatomy. You’re really taking off probably the lower two-thirds of the esophagus in most cases, and bringing up the bottom two-thirds of the stomach into the chest, and connecting those two things together. It’s both technically challenging, and the immediate recovery period’s challenging, but more importantly, the long-term alterations can be certainly significant in a lot of people.
What are some complications of the procedure?
Dr. Carroll: The anatomy is gone, so the normal G-junction reflux barrier has been removed. It’s surprising that with all of the changes that have been made, many people can live with a real minimum of any post-operative symptoms, but it can be tough for other people. They can have the stomach emptiness impaired --the stomach is now literally up in the chest next to your heart, and you can and do get a lot of early digestion reflux back up in the chest, so the initial reflux you had can be even more problematic after the surgery. With the limited size of the stomach and the delayed emptying, eating can sometimes be a challenge, so it’s a number of upper digestive things that can be rough for people.
How long does it take to recover from that procedure?
Dr. Carroll: It’s a major thoracic surgery. You would be in the hospital two or three weeks typically, potentially longer, if any other slow healing issues came up. Any surgery where you have to go into the chest can have a painful recovery time, and so it would certainly be maybe a good four to six weeks at home, kind of getting your strength back and getting you back on your feet would probably be typical.
How does this newer radiofrequency technique that you’re using differ from the laser procedures?
Dr. Carroll: It is more targeted, because the esophagus wall is very, very thin – three or four millimeters -- and the area in Barrrett’s that is a problem is maybe 500 microns, it’s very, very thin. The good thing about this new radiofrequency treatment is it’s able to target just the superficial problem layer. The other treatments went deeper which took on new problems -- scar tissue and strictures and things like that -- so the great thing about this is it’s been able to sort of smoothly peel off just the very superficial epithelium that’s the problem area. That’s the big thing -- not going too deep, going just the right depth, and also the delivery system is easier. It’s a one-time treatment, whereas some of the other treatments would be succession, maybe three times in the hospital over the course of a week. From the patient’s standpoint, it’s a pretty routine endoscopy under sedation, and one treatment, and based on the area you’re treating, we’ll have them come back in a few months later, and have several different follow up treatments.
How does the procedure work?
Dr. Carroll: It’s essentially using thermal energy to go ahead and damage the tissue and to destroy the cells. It delivers radiofrequency energy that really just causes a coagulating heat effect that really just destroys, burns off the very superficial layer, but doesn’t go deeper. The esophagus, like any part of the body, heals really remarkably quickly. Once the inner layer is peeled off, it will be visually ulcerated and swollen right away, but if you create an acid-poor environment, there’s no reflux injury. Healthy cells grow back in remarkably quickly, and then you get healthy new squamous mucosa, that replaces where the Barrett’s was.
Are there any risks associated with this procedure that don’t accompany the traditional major surgery?
Dr. Carroll: It’s certainly enormously less morbid than major thoracic surgery, but it’s not without its risks. They’ve been almost negligible, but whenever you do an endoscopy, there’s always a remote risk of bleeding or tearing the lining, and we’ve not see this here. There have been isolated episodes reported around the country, but I think on the order of one or two type of thing, and there have been thousands and thousands of procedures done. It’s not without risks, but they’re unanticipated, very minimal, and leagues less than what you would take on with a thoracic surgery.
How long have you been doing this procedure?
Dr. Carroll: We’ve been doing it about two years. It’s been looked at around the country maybe a year or so, and there’s been pioneering work looking at some type of what’s called ablato-therapies in the last 10 years. A lot of them have kind of come and gone. This has become more mainstream in academic centers in the last two years or so, and we’re getting more and more data, and it keeps getting very encouraging.
When should someone who has heartburn consider having this procedure?
Dr. Carroll: The traditional recommendations have been -- if anyone has heartburn three times a week or more, for more than a year or two, that’s a high enough risk factor where they should come in and have an endoscopy. The trouble is that there are many people with heartburn who are asymptomatic who get esophageal injury, get Barrett’s, can get precancerous changes, and they may never get symptoms, and we may meet them only when they get a cancer that’s developed. There is no consensus, but a lot of people think that we should talk about screening people with upper endoscopies in a similar way that we screen for colonoscopies for colon cancer prevention, so that’s being debated. I think that if there’s been any hint of reflux symptoms at all in someone over 30 or so, I think it’s not unreasonable to do an endoscopy, look and just to ensure that this person hasn’t developed Barrett’s.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Office of John Carroll, M.D.
Georgetown University Hospital
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