A new treatment for pre-cancerous changes in Barrett’s Oesophagus arrives at the Royal Liverpool University Hospital.
Barrett’s Oesophagus is a pre-cancerous condition where the normal lining of the gullet (oesophagus) is replaced by cells that would normally line the stomach (a process called metaplasia). This develops as a result of longstanding exposure to refluxed stomach acid, enzymes and bile, causing injury and inflammation. It is easily detectable at routine endoscopy. Up to 1 in 5 patients with Barrett's oesophagus may progress through a number of increasingly severe precancerous stages (dysplasia) and 1 in 10 of these will eventually develop cancer of the oesophagus. Many patients who have a diagnosis of Barrett’s oesophagus therefore undergo surveillance endoscopy every 2 years with multiple biopsy specimens. The aim is to detect early pre-cancerous stages (dysplasia) before they develop into cancer.
Progression to low-grade dysplasia (LGD) indicates that cells exhibit more “cancer-like” architecture, thus warranting an accelerated surveillance endoscopy and biopsy program every 6-12 months. There is no consensus on how to treat low grade dysplasia in Barrett’s oesophagus as the risk of progression to cancer remains low (3-15% over 5 years). High-grade dysplasia (HGD) is the stage which immediately precedes the occurrence of cancer, but it is not possible to predict how soon cancer will develop. Up to 60% of patients with HGD will develop cancer within 5 years. HGD is therefore usually treated by surgery, which carries high operative death rates (between 5-10%) and very high serious complication rate (between 40-60%). Additionally, many elderly patients are not fit for this type of major surgery.
The goal of achieving curative endoscopic treatment of dysplasia or early cancer in Barrett’s oesophagus is now a reality. Using a combination of endoscopic removal of visibly dysplastic tissue (endoscopic mucosal resection), followed by an ablation technique to destroy the remaining Barrett’s mucosa, research has shown selected patients can achieve survival outcomes comparable to that of surgery.
The ideal ablative technique has yet to be identified but 2 have commonly been used; argon plasma coagulation (APC) and photodynamic therapy (PDT). Success rates for complete ablation of Barrett’s oesophagus, with or without dysplasia using these ablation methods vary from 40 -75%. Several complications can arise from these treatments including narrowing of the oesophagus (stricture) and even oesophageal perforation (making a hole in the wall of the gullet). PDT causes sensitivity to light, problematic even in the Liverpool climate.
HALO radiofrequency ablation is the newest technique available in the endoscopist’s arsenal. HALO uses short pulses of radiofrequency energy to selectively destroy the abnormal Barrett’s oesophagus lining, allowing the normal lining to regrow in its place. Unlike APC & PDT, the technique appears well tolerated & relatively free from side effects, with minimal stricture formation. Experience with the device has grown in USA & Europe, with excellent results in terms of high grade dysplasia & early neoplasia being published in the endoscopy literature. A complete response for LGD & HGD can be expected in between 80-100% of patients, with complete resolution of Barrett’s changes in a similar number of cases.
HALO treatment is now available at the Royal Liverpool University Hospital as part of the upper GI cancer service, which also includes tri-modal endoscopic imaging, endoscopic ultrasound and other advanced endoscopic techniques. Dr Howard Smart, lead clinician in upper GI cancer, supported by medical and nursing colleagues, offers treatment with HALO as part of a national study, co-ordinated from University College Hospital London, into the effect of this treatment in patients with both Barrett’s dysplasia and squamous dysplasia of the oesophagus. The Royal Liverpool University Hospital is one of only 5 centres nationally to undertake this study using this exciting and highly promising new technique.
For further information please contact:
Dr Howard Smart
Consultant Gastroenterologist & Advanced Endoscopist
0151 706 3557
Gastroenterology Nurse Practitioner
0151 706 2653