Zubair Malik, MD, Gastroenterologist at Temple University Hospital talks about using the WATS3D brush to get more cells from the Barrett’s Esophagus to detect cancer.
Interview conducted by Ivanhoe Broadcast News in May 2018.
This brush that you’re using, do I call that WATS3D or is that just part of the mechanism?
Dr. Malik: That’s the WATS3D brush and then the WATS3D they have a reconstruction in a computer at the facility.
So the improvement over this is you used to biopsy but what does this do that catches more of it?
Dr. Malik: When you brush the surface of the Barrett’s Esophagus you pick up more of the tissue from the Barrett’s Esophagus. So traditionally when you do pinch biopsies at best you can cover about twenty percent of the Barrett’s tissue leaving eighty percent un-sampled. Now you’re hoping that your sampling is good but you can easily miss things. With the brush what it does is it brushes against the Barrett’s tissue and you’re trying to cover more of that tissue. You’re probably not going to get a hundred percent but maybe seventy percent, eighty percent and that’s a lot more than the twenty percent we were doing before. And it just helps you another way to find anything that’s abnormal in that tissue.
So the Barrett’s Esophagus and dysplasia those are two separate things right?
Dr. Malik: Dysplasia is part of the Barrett’s Esophagus, so Barrett’s Esophagus has different stages in the development. The earliest stage of Barrett’s Esophagus is just intestinal metaplasia esophagus, those are the earliest changes. Then it can progress to low grade dysplasia then high grade dysplasia then cancer of the esophagus. Its part of it but it can progress that way.
These are things that are coming up from the stomach that are causing that to happen in the higher digestive system. So what kicks that off to begin with?
Dr. Malik: There are lots of things that can cause acid reflux in patients. It can be related to weakness of the esophagus or not having enough saliva if there is weakness in the sphincter muscles of the esophagus that can lead to that. Or something called a Hiatal hernia where the bottom of the esophagus and the diaphragm muscles don’t line up properly and that can lead to reflux. Also in today’s society obesity is a big cause of acid reflux as well as some issues in the stomach where you can over produce acid.
You know if you’re obese you can do something about that, as you get older I’m assuming that sphincter is probably not working as well.
Dr. Malik: Often times for patients the sphincter loosens up with age and that can lead to problems. Hiatal Hernias are not uncommon and that can also lead to a weaker sphincter and lead to a lot of reflux.
What can patients do to prevent this from happening to them if anything?
Dr. Malik: So a healthy diet, weight loss, good exercise, things like that are always very helpful. There’s things they can do with their lifestyle, for example when they eat make sure they’re sitting upright, drink a lot of water with it make sure they stay upright after eating for a period of about an hour. Patients that do have some reflux what they can do is elevate the head of their bed when they sleep at night to try to prevent that reflux from coming up at night.
During the day I’ve heard things like they’re clearing their throats frequently and what are some other things?
Dr. Malik: So typically the symptoms are a burning in the chest maybe a sour taste in the mouth, and then other things they can feel there’s lots of other symptoms but cough, some people actually end up having specific types of lung diseases. You can have sinus problems, problems in the back of your throat. You can even have chest pain that gets worked up for a heart cause and they don’t find any reason from your heart to cause that chest pain and that sometimes can be from reflux as well.
So I think Sharon described, I know she had stomach surgery many years ago and then she had problems with hernia. So what was her specific problem and how did you actually discover that?
Dr. Malik: She had a few problems actually. When she came in to see us the first time she had told us that she had Barrett’s Esophagus and she also had the gastric surgery but she was having some pain in her belly as well. So we found that the surgery where they sewed the small intestines to the end of the small stomach pouch had actually closed up so things couldn’t drain forward and it led to a lot of reflux. What eventually happened she had developed what’s called a fistula, a new tract where the food was supposed to be going to her old stomach which is excluded and it’s not supposed to get food there but there was a track that developed there so that could lead to even more acid coming in to her stomach and in to her esophagus.
So when she came in and you actually used this particular brush will you describe how you used it on Sharon and then what you found?
Dr. Malik: Typically what I do is for patients that have Barrett’s Esophagus sometimes I do a special scan called a volume metric laser endomicroscopy. We did not do that for Sharon but for many patients we do that. That can look a little deeper at the tissue to see if there’s anything deep. Then we take the brush and we brush the whole area that Barrett’s Esophagus and she had a pretty significant area. It was about six centimeters in length and so we brushed that whole area as best we can and collect us much tissue as we can. And then after we do the brush we still take some biopsies throughout that area because that’s a little deeper. And when we got the results the pinch biopsies, the regular biopsies we did, just showed that she had intestinal metaplasia the earliest stages of Barrett’s. And for that we typically don’t do any treatment we can just watch those patients because their risk of developing cancer is pretty low. But when we did the brushings we found that she had low and high grade dysplasia and that’s very concerning to develop in to cancer and has a pretty high progression rate, up to twenty percent per year.
Was it the same area that you did the initial biopsies and the brush scrapping?
Dr. Malik: Yes, we do it at the same area. We try and cover as much of that so we brush the whole Barrett’s area. Then we take the biopsies from that same Barrett’s area.
And point to yourself if you would where your scrapings were.
Dr. Malik: The esophagus is probably from where your chest bone ends all the way up to your mouth. But usually the Barrett’s is in the lowest part of the esophagus. So down here right where your chest meets your abdomen.
She had a friend who told her she didn’t look very good and she needed to go to the doctor and if not for that she would not have found her way to you. So how lucky was it for her that she ended up in Temple?
Dr. Malik: It was very lucky that she ended up in Temple because this is something we do here we can take care of that. I would recommend for other people if you’re having a lot of symptoms of reflux or just not feeling well it’s important to get to your doctor and sometimes they’ll send you over to the GI specialist if you need it. Because often times when you have those symptoms and it’s not controlled we often need to intervene or take a look down there at least to make sure there’s no problems.
And how common is this deeper look with this brush around the United States and not just here in Philly?
Dr. Malik: It’s becoming more and more widespread but it’s not done everywhere yet. It is still a newer technology but there are several centers in Philadelphia and there’s many centers around the country that are using this brush.
So a laundry list if you will of symptoms that patients would need to be aware of.
Dr. Malik: So any burning in the chest, sour taste in the mouth that’s typical of reflux. But more concerning is if you’re having trouble swallowing, food gets stuck on the way down or you have pain when swallowing at all. If you’re having vomiting, if you’re having regurgitation, if you’re starting to lose weight or your blood counts are starting drop those are very concerning and you need to get seen immediately.
So once the results came back from the brush and you found out that her case was more severe than anticipated, what did you do?
Dr. Malik: The first thing I did was talk to her about the results and then I spoke to one of my colleagues in surgery because she had the narrowing that wasn’t allowing things to drain from her surgical stomach pouch. I talked to my colleague we got her in with him, he took her for surgery redid that area, so made an open drain for her so things could drain and she wouldn’t have so much reflux. And then after that, after she healed up for about a month or two we brought her back and we started treating her Barrett’s Esophagus and so far she’s undergone one treatment. And the way treatment works for Barrett’s Esophagus we can either do it with a burning therapy or a freezing therapy. We use microwave ablation or we use liquid nitrogen to freeze it. And then we treat them and bring them back in three months for another treatment and we keep doing that until it’s all the way gone. So she’s had her first treatment, she should be coming back in about another month or so for her next round of treatment.
And how complicated is either the ablation or the micro freezing? How long does that take, recovery?
Dr. Malik: It takes about, depending on how big your segment is, anywhere from twenty to forty minutes to do. It’s not too complicated, there’s minimal complications with it after. Some people do feel a little bit of pain afterwards for a short period of time. A few people do develop some narrowing’s of the esophagus after it but that’s easy to treat for us, we can open that back up. Typically speaking patients get it and go home the same day and by one to two days later they’re totally back to normal eating, drinking and doing all their normal activities.
So after these treatments the number of which is three or four?
Dr. Malik: It varies minimum is usually about two. It depends how each person responds. A lot of people are good with just two or maybe three but some people have had to go out to even six or seven before they’re all the way gone.
But once those cells are gone either through freezing or ablation the problem stops?
Dr. Malik: No not necessarily because a lot of the patients still are set up for reflux so we have to also control their reflux. Often times we can do it with just medication but sometimes when medication is not enough they have to undergo surgery to prevent the reflux. Since they’ve had it they’re always at higher risk to redevelop it, it will never go away or the risk doesn’t go away once you treat it. We always keep an eye on them. After we treat them we do periodic endoscopies to make sure that it doesn’t come back.
END OF INTERVIEW
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