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Procedures

Theses pages describe the various procedures that may be used in the removal of dysplastic cells and prevent progression of oesophageal cancer. In some cases. they may also be applicable to early stages of oesophageal cancer.

Endoscopic Mucosal Resection


EMR is a technique whereby a small area of cells is removed using a wire snare passed through the endoscope.

The endoscopist identifies a suspect area (usually "lumpy") that he sucks into a special cap permitting a rubber band to be placed around it. The heated wire snare is then used to remove the lump which will be sent for analysis at the pathology laboratory.

EMR is frequently used in combination with other ablation techniques, e.g. Radio Frequency Ablation. EMR removes the lumpy bits first and RFA cleans up the smoother areas.

Endoscopic Submucosal Dissection

ESD is a recent development from Japan and may be used on early tumours that have not entered the muscle layer.
The perimeter of the lesion to be removed is marked. A suitable fluid is next injected into the submucosal layer to separate and raise the lesion which is then cut away using fine knives via the endoscope.

ESD can remove larger areas than EMR.

Radiofrequency Ablation

RFA is still sometimes referred to as Halo therapy (though that name is trademarked by another company).
BarrxTM RFA is applied during an endoscopy procedure to destroy the abnormal Barrett’s oesophagus lining. The lining which regrows is usually normal.

There are two different types of Barrx RFA device. The Barrx 360 device treats the entire wall of the gullet. The Barrx 90 device is similar, but treats a smaller area.

Patients are usually treated with the Barrx 360 device initially and if, at the next endoscopy, there is any abnormal Barrett’s oesophagus lining left, retreatment with either the Barrx 360 or Barrx 90 device, depending on how big the area needing treatment is.

During the Procedure
Using standard endoscopy techniques, the physician activates and controls the different functions of the Barrx 360 System.

Ablation

  1. The Barrx 360+ Ablation Catheter has a balloon at the tip covered by a band of radio frequency electrodes.

  2. Once the electrodes of the balloon are positioned on the desired treatment area the balloon is inflated and a short burst of energy delivered.

    • The design of this technology limits the energy delivery to a depth clinically proven to remove the diseased tissue while reducing the risk of injury to the deeper and healthy tissue layers.

    • The Barrx 360+ Ablation Catheter ablates a 3cm circumferential segment of Barrett's tissue within the oesophagus

  3. For patients with Barrett's Oesophagus lesions longer than 3cm, the Barrx 360+ Ablation Catheter is simply repositioned and the ablation steps are repeated.

A report in New England Journal of Medicine in May 2009 concluded, "In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression." [tr-iii]

A July 2015 report ,"Comparing outcome of radiofrequency ablation in Barrett's with high grade dysplasia and intramucosal carcinoma: a prospective multicenter UK registry" [tr-iv] concluded, "The Registry reports on endoscopic therapy for Barrett's neoplasia, representing real-life outcomes. Patients with IMC were more likely to have visible lesions requiring initial EMR than those with HGD, and may carry a higher risk of cancer progression in the medium term." affirming the efficacy of combination of the two modalities.

Cryotherapy

Cryoablation freezes the lesion rather than burning it as in RFA.

A 2011 paper on Cryotherapy for Barrett's Oesophagus and Oesophageal Cancer reported: "Endoscopic spray cryotherapy is a relatively new ablative modality for the treatment of gastrointestinal diseases. Spray cryotherapy rapidly cools tissues by spraying them with either liquid nitrogen or rapidly expanding carbon dioxide gas. Initial, nonrandomized and uncontrolled studies show success rates comparable to other ablative modalities for the treatment of Barrett's esophagus with high-grade dysplasias." [tr-v]

A 2012 report prepared by the Australian Safety and Efficacy Register of New Interventional Procedures for the American College of Surgeons in May 2012 found: "The results from these studies suggest that endoscopic spray cryotherapy is effective in treating patients with Barrett’s HGD and early esophageal cancer, including those who have failed other forms of treatment, at least in the short-term. Specifically, cryotherapy treatment was associated with a complete eradication of Barrett’s HGD in 72-100% of patients. For patients suffering from early stage esophageal cancer, a complete response to cryotherapy treatment was observed in 61-100% of patients." [tr-vi

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Photodynamic therapy


This treatment is particularly useful when there is high grade dysplasia but no nodules. Here the changes are often widespread and are difficult to see by endoscopy.

PDT can be used to treat a large area.

This treatment does not aim to completely remove the Barrett’s Oesophagus although it sometimes does so.

If you have PDT, you will be given a drug which sensitises you to light. You then have an endoscopy, during which light is shone at the area which needs treatment. The combination of the drug and the light kills the targeted cells.

This treatment takes about 45 minutes. The treatment can be repeated two or three times at an interval of three months if necessary and has been shown to reduce the likelihood of cancer developing by 50 per cent over at least five years.

The treatment, using a drug called Photobarr, is licensed and has been approved by NICE for treating high grade dysplasia in Barrett’s Oesophagus.

The drug used will cause your skin to be sensitive to light for up to three months.

Take care to avoid bright sunlight during this time.

A paper published in World Journal of Gastroenterology in November 2013 comparing PDT with RFA, concluded, "In our experience, RFA had higher rate of Complete Remission from Dysplasia without any serious adverse events and was less costly than PDT for endoscopic treatment of Barrett's Dysplasia." [tr-vii]


With the advent of newer ablation methods like RFA, PDT is not so widely utilised nowadays.

Argon plasma coagulation

This technique is mainly used to seal bleeding lesions of the oesophagus.
Argon gas is fed through an endoscope and ionised by the discharge of high energy electricty to seal the blood vessels.

Laser therapy

Intense energy burst using laser via an endoscope may also be used to seal blood vessels.

Multipolar electrocoagulation

Like the two previously mentioned procedures, MPEC can seal blood vessels.

All three of the above procedures may also be used to ablate small distinct areas of Barrett's Oesophagus.
A comparison of the efficacy of MPEC and APC in ablating Barrett's published in Gastrointestinal Endoscopy in 2005 concluded, " Although there were no statistically significant differences, ablation of Barrett's esophagus with pantoprazole and MPEC required numerically fewer treatment sessions, and endoscopic and histologic ablation was achieved in a greater proportion of patients compared with treatment with pantoprazole and APC." [tr-viii]

Oesophagectomy

Surgical removal of part or the whole of the oesophagus and or part or whole of the stomach may be performed to remove oesophago-gastric cancers.

The amount removed and the type of surgery offered depends upon the extent and stage of the cancer and the health of the patient.

The diagram shows the typical reconfiguration where just the oesophago-gastric junction has been removed. [Image thanks to Cancer Research UK]


This type of surgery used to be offered to deal with cases of High Grade Dysplasia to prevent progression to cancer but with the advent of highly effective ablation methods, this is not so common.

There are two ways of accessing the oesophagus to perform the operation: through the chest / thorax (the Transthoracic "Ivor Lewis" approach) or through the abdomen and the hiatus hole, where the oesophagus passes through the diaphragm (the Transhiatal "Kirshner-Nakayama" approach).

The technique used depends upon the extent of the cancer, how much of the oesophagus is to be removed (and whether any of the stomach is also to be removed) and the surgeon's skill and preference.

The Ivor Lewis approach is that most commonly favoured since it provides greater access to the oesophagus but usually requires two major incisions - a midline incision running up from just above the navel and a right thoracotomy incision running around the right shoulder blade resulting in a "shark bite" scar. A technique recently developed by a Southampton surgeon, however, now permits Ivor Lewis surgery to be conducted laparoscopically. [tr-ix]

Depending upon how much has to be removed, the top of the stomach is then typically joined to the throat with the stomach sitting within the chest. For most people, with care, food may be eaten as normal (though in small portions). Some may require foods to be delivered by a J-tube (jejunostomy feeding tube) inserted through the abdomen into the small intestines.

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