Barrett

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Barretts esophagus

• Dr. Reza Bagheri
• General Thoracic Surgeon
• Associate professor
• Of Mashhad university of medical sciences

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History

• First dircription by Tileston in 1906 and
  barretts in 1950

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Anatomy of GEJ
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Definition

• The present difinition requires both endoscopic
  recognition of colummar lining and
  biopsy-established intesttinal metapolism in the
  esophagous.
• Sampliner and associates (1988) defined short
  segment (3 cm or low) and long segment (more than
  3 cm) barretts esophagous.

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Epidemiology

• Barretts esophagus in the only known precursor
  to esophageal adenocarsinoma.
• In 1991 Blot and colleagrres report that
  esophageal adenocarsinoma had the most repidly
  increasing incidence of any cancer in USA (in
  men).

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Epidemiology

• A population-based study of GERD by Locke (1997)
  reported that 40 of the adult population has
  symptomatic reflux .
• Multiple study in USA included that most of the
  increase incidence of Barrett's esophagus may
  have been due to detection.

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Etiology

• (1) GERD the storngest and most consistent risk
  factors indentifid for esophageal Adenocarcinoma
  are symptomatic GERD and being overweight

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Etiology
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Etiology

• GERD ? esophageal acid exposure and bile
  exposure ? Barretts esophagus ? esophageal
  Adenocarcinoma
• Chronic GERD is the mian risk factors developing
  Barretts esophagus.

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Etiology

• 2) Obesity
• 3) Cigarette smoking and a high-fat diet
• - Smoking as potential risk factor for developing
  ESO. AC (SCC ?)
• Smoking cessation dose not appear to reduce the
  risk of ESO. AC (initiator in progression to ESO.
  AC)
• Smoking being a risk for adenocarcinoma and
  continued smoking being a risk for SCC
• 4) Chemotherapy drug (?)

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Etiology

• Multiple study failed to identify a genetic
  component
• Possible role of aspirin and (NSAIDS) in reducing
  the risk of esophageal adenocarcinoma and
  Barretts esophagus (COX-2 over expression)

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Clinical presentation

• M/F 4/1
• Patients typically present with symptoms of GERD
  (heart burn and regurigation 10) and may also
  odynophagia-dysphagia-noncardiac chest
  pain-hematemesis, melena or less extra esophageal
  symptoms (hoarseness-asthma-dental erosion.
• Increase Frequency and duration of heart burn
  were associated with likehood of Barretts
  esophagus.
• 40 of patients who developed esophageal adeno
  carcinoma have no antecedent symptom of reflux

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Clinical presentation

• The cause of dysphagia (alarm symptom)
• (1)stricture (2)motility disorder
  (3)adenocarcinoma
• The cause of bleeding
• (1) ulcer (2) errosive gastritis
• Complications of Barretts esophagus
• (1) ulcer (2) stricture (3) dysplasia (4) cancer

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Endoscopy land mark biopsy technique

• Land mark
• Distance from the incisor
• Ora serrata (GEJ)
• Diaphragmatic impression

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Endoscopy land mark biopsy technique
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Endoscopy land mark biopsy technique

• Four-quadrant biopsies should be obtained using
  the turn and suck method at 2 cm intervals
  through the columnar-lined esophagus from distal
  to proximal.
• Detection Barretts length.

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Pathology

• Last subtype of Barretts histopthology
• Gastric fundic gland mucosa. ? normal epithelial
• Cardiac gland mucosa (Junctional) ? normal
  epithelial
• Intestinal (specialzed) metaplasia. ? cause of
  cancer
• New histopathologic classification
• Negative for dysplasia
• Indefinite for dyplasia
• Low grade dysplasia
• High grade dysplasia
• cancer

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Endoscopic sreening

• 1.3 to 5 of patients with esophageal
  adnocarcinoma had a prior diagnosis of Barretts
  esophagus.
• Median age
• Barrette esophagus (40 y)
• Esophageal adenocarcinoma (64 y)
• Recommendations for routine screening of GERD to
  detect Barretts esophagus are contraversial
  against
• 90-95 of patients with GERD do not have
  Barretts
• Low absolule incidence of esophageal
  adenocarcinoma
• Endoscopy complication.
• At the present time there is no national policy
  on screening (Dicision on a case-by-case)

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Endoscopic Biopsy

• Endoscopic biopsy is recommended for patients
  with Barretts esophagus

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Barretts esophagus
Low grade dysplasia
Intestinal metaplasia without dysplasia
High grade dysplasia
Medical treatment
Another pathologist ? Repeated biopsy ?
Two biopsy (3 years) One biopsy per year
Repeated Biopsy
High grade dysplasia Cancer ?
Careful survillance ? Endoscopic ablation therapy
? Esophagectomy ?
Negative
Positive
Esophagectomy ?
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• Both low grade dysplasia and high grade dysplasia
  appear to regress
• Low grade dysplasia 3 cancer
• 6.5
• Regress to no dysplasia

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Treatment

• Barretts esophagus without high grade dysplasia
  or cancer
• (A) First medical treatment
• ? (proton pump inhibtor better than H2 blocker)
• ? 95 with errosive gastritis and barretts ulcer
  healed.
• ? decrease DGE (bile) reflux (decrease secretion)
• ? medical therapy cant regress Barretts EP but
  improved symptoms.

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Surgical treatment

• Antireflux surgery cant regress Barretts EP and
  complete prevention of Adeno carcinoma.
• Indication for surgery
• Transmural penetrated ulcer
• Sever stricture
• Perforated ulcer
• High grade dysplasia cancer.
• Massive uncontroled bleeding from ulcer
• Fistula formation

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Stricture
Endoscopy and rule out cancer
Dilation medical theraphy
No reponse or relapse
Improved
Endoscopy Survillance
Esophageal length
Short
Normal
Nissencollis gastroplastydilation
(abdominal)NissenDilation
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Barretts ulcer
Medical treatment
Response
Good
Failed (after 4 m treatment )
Endoscopic survillance
Antireflux surgery
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Barretts esophagus with high grade dyplasia

• (1) Carefull surveilance
• 40 regress with medical treatment if undected
  adenocarcinoma.
• 0, 1, 3, 6, 9 ? first years
• Disadvantage
• A- patients discomfort
• B- risk of undetected cancer
• C- endoscopy complication

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• (2) Esophagectomy (standard of cure)
• For patient for high grade dysplasia with or
  without adeno carcinoma (only option that can be
  curative and eliminates the need for
  surveillance.
• Advantage
• (a) chance of co-existing cancer in high grade
  dysplasia (38 patient that esophagectomy for
  high grade dysplasia have cancer in surgical
  specimen.
• Disadvantage
• 1.7 mortality
• (b) major complication 10 (overal 20)
• Number of surgery per month .
• Transhiatal or transthoracic (total
  esophagectomy) and esophagogastric anastomosis in
  neck .

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• (3) Endoscopic ablation for high grade dysplasia
  or early esophageal adeno carcinoma
• (A) Photodynamic therapy (PDT)
  continued endoscopic surveillance.

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