Treating Barrett’s esophagus: Watch and wait
Barrett’s esophagus is a relatively common condition in patients with gastroesophageal reflux disease (GERD). It occurs in 10-15 % of patients with GERD and carries with it an elevated risk of developing esophageal cancer.
The management of this condition is debated. The most common recommendation is for observation with repeated endoscopies as often as once every three years. The objective is to detect progression of the abnormality to a state with an even greater cancer risk, called dysplasia (low-grade and high-grade), or to an early cancer, where the chance of cure is better than if detected in an advanced stage.
Learn more: What to expect from an upper endoscopy
Radiofrequency ablation: A promising new approach
Rather than this “watch and wait” approach, other management strategies for Barrett’s esophagus have been developed. The most recent and promising is called radiofrequency ablation (sometimes referred to as RF ablation, or Halo). The procedure involves using very controlled radiofrequency energy to eliminate or “ablate” areas of Barrett’s that have developed in the normal lining of the esophagus. Once the Barrett’s tissue is eliminated, the normal lining of the esophagus regenerates over several months.
What happens during the RF ablation procedure?
The ablation is done under sedation, in conjunction with a standard endoscopy. After precisely locating the area of Barrett’s tissue, a sausage shaped balloon, 3cm in length and containing special electrodes, is inserted through the mouth, into the esophagus, and positioned in contact with the area of Barrett’s tissue. A short burst of energy, less than 1 second, is delivered to the balloon’s electrodes and the undesirable Barrett’s tissue is ablated. Several areas can be ablated at a single setting but most patients must return for one or more additional treatments to assure that all of the areas of Barrett’s have been ablated.
After the procedure, patients are given a prescription for twice daily PPIs to control the symptoms of reflux. The RF ablation procedure does not affect the symptoms of reflux. The patients return yearly for endoscopies to ensure Barrett’s does not return. If it does, the area can be retreated.
Learn more: A closer look at RF ablation
Is ablation safe?
RF ablation is generally a safe procedure if performed correctly. There is some chest discomfort for several days following treatment. Occasionally a stricturing or narrowing of the esophagus can occur that is reliably treated with a simple procedure called dilation. The greatest concern is that there could be Barrett’s tissue that is located deeper in the esophageal wall than what is ablated. When the normal esophageal lining grows back there is a theoretical possibility that some of that deeper Barrett’s tissue can lie beneath that new lining. The term for this is “buried glands.” This can be a potential problem since these glands cannot be seen through the endoscope, yet carry the cancer risk associated with Barrett’s. Research suggests that this occurs only rarely with RF ablation.
Is RF ablation effective?
Extensive research suggests that RF ablation either prevents or delays the progression of Barrett’s esophagus to more serious state, including cancer. However, all of the research studies recommend follow-up endoscopies at specific time intervals such as 6 months, 2 years, or 3 years. However, since experience with the procedure has been less than 20 years, sufficient evidence has not been gathered to conclusively prove that RF ablation prevents cancer. To date, the medical literature does indicate that RF ablation makes the development of cancer less likely. The caveat is that ablation must be performed by an experienced physician on patients who will reliably return for follow-up endoscopies and be retreated if indicated.
When should RF ablation be offered?
The abnormality, Barrett’s esophagus, is the first step toward reflux-induced esophageal cancer. However, there are two additional steps that carry an even greater risk of cancer. These are called low-grade and high-grade dysplasia. The risk of cancer from Barrett’s esophagus is .5% per year or 2.5% over five years. If Barrett’s esophagus progresses to high-grade dysplasia, the risk of cancer over five years can be as high as 60%! The cancer risk for low-grade dysplasia lies somewhere in between.
It has been asserted that if a patient with Barrett’s undergoes routine endoscopies, progression to either low-grade or high-grade dysplasia will be detected and ablation treatment should be offered only at that time. Presently, there is a consensus that ablation should be recommended for high-grade dysplasia, somewhat encouraged for low-grade dysplasia, but not offered for Barrett’s esophagus without dysplasia. From a practical standpoint, this has resulted in insurance companies not covering RF ablation for Barrett’s esophagus.
If you are diagnosed with Barrett’s esophagus, it’s important that you understand the condition, the risk of cancer, and the management options available to you. Talk to your doctor if you think RF ablation might be right for you.