Dr. Starpoli is an expert in the evaluation and management of the premalignant known as Barrett's Esophagus, described by Dr. Norman Barrett in the 1950s. Barrett’s esophagus is a condition affecting the lining of the esophagus, the swallowing tube that carries foods and liquids from the mouth to the stomach. Barrett's esophagus is caused by injury to the esophagus from the chronic backwash of stomach contents (like acid and enzymes) that occurs with acid reflux. What takes place is a slow transformation of the cells of the esophagus to cells that appear like cells from the intestine. This process is called intestinal metaplasia. The presence of these cells increase the risk fo esophageal adenocarcinoma. The overall risk for the developement of esophageal cancer is approximately 0.5% annually.
In a study published in 2005, Barrett's esophagus was estimated to affect approximately 3.3 million adults over 50 years of age in the United States. The incidence of esophagus cancer has risen about six-fold in the U.S. since the 1970s. The average age at diagnosis of Barrett’s esophagus is 50 and men develop Barrett’s esophagus twice as often as women. Additionally, caucasian men are affected more often than men of other races. Barrett’s esophagus is uncommon in children.
There are no symptoms specific to Barrett’s esophagus, other than the typical symptoms of acid reflux (or GERD). Barrett's is felt to represent one of the most severe forms of GERD in terms of severe reflux exposure to the esophageal lining. Therefore, optimal and successful treatment of reflux is of paramount importance. Those suffering from longstanding, frequent, and severe reflux should seek care by a qualified orgainization.
The diagnosis is made by upper endoscopy and biopsy. The diagnosis requires several biopsies in "4 quadrants" and different levels of the involved esophagus. Additionally, there are some newer technologies used to obtain better tissue sampling. In general, patients with Barrett's require routine endoscopic surveillance.
There are several treatment options if you have Barrett's and they inlcude the following:
One option that your physician may recommend, after you have a diagnosis of Barrett's esophagus, is endoscopy with biopsy (examination of your esophagus and sampling of the tissue) at various intervals to detect progression to more severe stages of disease or cancer. The frequency at which you undergo surveillance may be dependent upon the stage (severity) of your Barrett's esophagus.
Surgical removal of the esophagus
Once Barrett's esophagus progresses to cancer, removal of the esophagus may be necessary to avoid cancer related death. Called an esophagectomy, this surgery involves removing the esophagus and top part of the stomach. A portion of the stomach is then pulled up into the chest and connected to the remaining normal portion of the esophagus or pharynx, creating a "new" esophagus. Because this is a major operation, there are significant risks.
Historically, surgery has been used for certain non-cancer stages of Barrett's esophagus (high-grade dysplasia) in an effort to avoid operating on more advanced cancer stages of this disease. However, in the last 5 years most high-grade dysplasia patients and even early cancer patients are treated with endoscopic therapy rather than surgery.
A number of methods have been used for treating Barrett's esophagus as a pre-emptive strike before the development of cancer. The intent of these interventions is to avoid cancer and cancer related death, but also to avoid the need for surgery and surgical-related adverse events and death. The endoscopic therapies employ a variety of means to remove the diseased lining of the esophagus. The following section briefly summarizes them.
Radiofrequency ablation (RFA) uses an an electrode mounted either on a balloon or endoscope to deliver heat energy to the diseased lining of the esophagus. A number of studies have demonstrated that RFA safely results in a high rate of complete eradication of Barrett's esophagus, as well as reduces progression of the disease to high-grade dysplasia and cancer. Because of a favorable safety profile, studies have been performed assessing the efficacy of RFA for the earliest stages of Barrett's, as well as later stages.
Endoscopic mucosal resection (EMR)
For areas within the Barrett's esophagus lining which are raised or depressed, and thus suspicious for cancer, a method called endoscopic mucosal resection (EMR) is used to remove the damaged lining. Using a snare delivered through an endoscope, tissue can be removed to a depth of about 2 mm and then evaluated to diagnose the seriousness of the disease. The benefit of EMR is that large biopsy specimens can be removed to render the lining flat. The disadvantage is that use of EMR for wide spread Barrett's has an unacceptable complication rate. Therefore, focal EMR for specific areas of concern has been followed 2 months later by RFA to safely and effectively remove the remainder of the Barrett's esophagus.
Photodynamic therapy (PDT) has been intended exclusively for treatment of the most severe stages of Barrett's esophagus, specifically high-grade dysplasia and early cancer. A light-sensitive drug is injected into the patient's vein 24-48 hours prior to endoscopy. The drug makes the diseased tissue sensitive to laser light. During an endoscopy, a laser light is delivered to the Barrett’s tissue through a catheter inserted into the esophagus. While still holding potential for some patients with advanced Barrett's esophagus, other treatments have become preferred in the last five years (RFA and endoscopic mucosal resection) due to their greater safety, lower morbidity and equal or greater effectiveness.
Cryotherapy involves spraying a super-cooled liquid or gas onto the diseased lining of the esophagus. There is a paucity of clinical evidence available for this method at this time, but this remains, potentially, an important tool that can be used againts Barrett's.