Procedures

A revolution in the treatment approach for early esophageal neoplasia has taken place in the past decade. Esophagectomy has gone from being the primary treatment for such patients to a rarely used salvage therapy. Multiple modalities, including EMR, ESD, RFA, cryotherapy, and APC, often used in combination, yield complete eradication of dysplasia and Barrett's in over 90% of treated patients. Due to the efficacy of endoscopic therapy, timely diagnosis of esophageal neoplasia to allow for the application of these less-invasive therapies is receiving more emphasis now than ever. The next important breakthrough in esophageal cancer will involve broadscale screening methods, to allow for early detection of esophageal neoplasia. From Endoscopic Treatment of Esophageal Neoplasia: A decade of Evolution (American Clinical and Climatological Association 2020)

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.

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.

Read a patient's experience of the procedure on the Barrett's Patient Support site, here.

From the UK NICE guidelines, Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management, published 8 February 2023, "There are 2 techniques for resection of suspected stage 1 oesophageal adenocarcinoma: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The evidence did not show superiority of 1 technique over the other so the recommendation does not specify which to use."

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.

     1. • 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.

You may read a patient's experience here: Patient experiences - Ablation

From this 2017 paper, Hybrid Argon Plasma Coagulation in Patients With Barrett Esophagus, APC was one of the first techniques used for the ablation of Barrett esophagus. However, the procedure is associated with risks for perforation, stricture formation, and buried glands, in which neosquamous epithelium grows over any remaining Barrett esophagus. Hybrid APC, which combines APC with submucosal saline injection, was developed to address these complications. The Barrett epithelium is lifted with a saline injection using a high-pressure water jet, creating a safety cushion under the mucosa. The Barrett esophagus can then be ablated more thoroughly and with a higher energy setting, without an increase in side effects or complications. 

From Endoscopy International Opes, December 2021 Benefit, tolerance, and safety of hybrid argon plasma coagulation for treatment of Barrett's esophagus: US pilot study. “Hybrid APC appears to be promising in the treatment of BE. The ablation protocol used in this study demonstrated efficacy, tolerability, and a safety profile similar to radiofrequency ablation. Given the significant price difference between hybrid APC and other modalities for Barrett’s ablation, this modality may be more cost-effective.”

From the UK NICE guidelines, Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management, published 8 February 2023, "The evidence indicated that both radiofrequency ablation (RFA) and argon plasma coagulation (APC) are effective in reducing the risk of recurring oesophageal lesions in people who have received an endoscopic resection for high-grade dysplasia. However, the committee noted that for very long segment Barrett's oesophagus RFA might be more practical than APC, which has a significantly smaller ablation catheter than RFA."

Multipolar electrocoagulation (MPEC)

Like previously mentioned procedures, MPEC can seal blood vessels.

All 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]

From a September 2014 study Systematic review and meta-analysis of endoscopic ablative treatment of Barrett's esophagus. "There are no studies demonstrating the benefit of indicating cryotherapy or laser therapy for BE endoscopic approach. APC ablation was found to have superior efficacy compared with PDT and ablation through APC and MPEC was found to present effective, similar results. Radiofrequency is the most recent approach requiring comparative studies for indication."

Cryotherapy

Cryoablation freezes the lesion rather than burning it as in RFA

Cryotherapy is an ablation modality relying on freeze-thaw cycles to promote cell death through intracellular ice crystal formation, ischemia, and apoptosis. Currently, 2 different cryotherapy systems are available for esophageal use. The first is cryospray ablation, which involves repetitive applications of liquid nitrogen. The second system, cryoballoon ablation, freezes the esophageal mucosa with liquid nitrous oxide using a compliant balloon. To date, studies have shown that cryotherapy is an effective and safe method for eradicating Barrett's esophagus; however, larger prospective series with longer follow-up are warranted to determine the clinical utility of cryotherapy in the treatment of Barrett's esophagus. From Updates in Cryotherapy for Barrett's Esophagus (Gastrointestinal Endoscopy Clinics of North America October 2020)

From a 2018 paper in Gastrointestinal Endoscopy,  Focal cryoballoon versus radiofrequency ablation of dysplastic Barrett’s esophagus: impact on treatment response and postprocedural pain. “In this multicenter, nonrandomized cohort study, we found no differences in efficacy after a single treatment with CRYO and RFA for short-segment BE. Patients reported less pain after CRYO as compared with RFA. Moreover, CRYO patients used fewer analgesics. Our results suggest a different pain course favoring CRYO over RFA, but a randomized trial is needed for definitive conclusions.”

"Cryotherapy is an ablative modality for the treatment of Barrett’s esophagus, involving cycles of freezing and thawing to induce cell death. Cryotherapy potentially enables deeper tissue ablation with less post-procedural pain by its anesthetic effect, and possibly less stricture formation by preserving the extracellular matrix.

"The current available systems for esophageal application are cryospray ablation using liquid nitrogen, and cryoballoon ablation using liquid nitrous oxide.

"Although cryotherapy is safe and effective, the exact role for cryotherapy in the management of Barrett’s esophagus still needs to be established."

Photodynamic therapy (PDT)

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]

This 2015 paper from Gastrointestinal Endoscopy, Comparison of endoscopic treatment modalities for Barrett's neoplasia. found "complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT." (Ps-PDT = porfimer sodium photodynamic therapy)

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

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.

You may read a patient's experience here: Patient Experiences - Oesophagectomy

A summary from Translational Gastroenterlogy & Hepatology, 2021: Endoscopic therapies for Barrett’s esophagus

“Among ablative techniques, RFA continues to have the most data to support its safety, efficacy, and treatment durability. PDT, although effective, is limited by its high cost and stricture rate, and therefore has fallen out of favor. However, cryotherapy ablation has shown promise in its ability to induce durable CE-IM while minimizing complications, with some studies proposing a potential role for cryotherapy after RFA treatment failure. Cryotherapy, as well as the novel Hybrid-APC technique, would benefit greatly from robust head-to-head trials to better guide the endoscopist’s choice of treatment modality. Regardless of modality used, patients should continue in a strict surveillance protocol after EET due to the unpredictable risk of recurrence.”

Ablation of Non-Dysplastic Barrett's Oesophagus

This is not normally recommended for the following reasons:

1. The risk of Barrett's cells mutating is very small. With acid suppressants and surveillance, it is nearly zero, as proved by patients in BarrettsEsophagusAwareness Facebook group (over 11,000 members and 3 deaths to adenocarcinooma in 9 years).

2. All procedures carry risk. Risk of perforation of oesophagus during ablation is probably about 1 in 2000.

3. Because Barrett's developed previously, it is likely too develop again.
   According to the study cited in this article from Gastrointestinal Endoscopy in June 2023 , Location and appearance of dysplastic Barrett’s recurrence after endoscopic eradication therapy, "8.3% of the patients developed recurrence of dysplastic or neoplastic BE, with the majority being detected at the gastro-esophageal junction on random surveillance biopsies." although "No biopsy samples from areas of tubular esophageal neo-squamous epithelium that appeared normal on visualization yielded intestinal metaplasia, dysplasia, or neoplasia."

4. Patients receiving ablation therapy are recommended to remain on acd suppressants and surveillance as before (to ensure no new Barrett's).

5. Patients previously worried about their Barrett's muataing to cancer, will be worried about new Barrett's occurring instead.

Page updated 29 November 2023