Abstract
Non-dysplastic Barrett’s esophagus (NDBE), this is columnar lined esophagus (CLE) with intestinal metaplasia (IM; goblet cells within CLE), results from gastroesophageal reflux disease (GERD) and harbors a 0.5 % annual risk for the development of esophageal adenocarcinoma (comparable to the risk of a colorectal polyp to proceed to colorectal cancer). Radiofrequency ablation (RFA) eliminates NDBE in 70 % and up to 97 % of the cases after one and two to four RFA treatments, respectively, and remains durable in 92 % of the cases after 5 years.
Medical GERD therapy alters the pH, but not the occurrence of the reflux. In contrast to that, effective antireflux surgery eliminates any reflux (acidic and non-acidic), and most importantly, impairs the reflux of compounds, which are suggested to aggravate GERD and promote the cancer development (i.e. bile acid, pancreatic enzymes). Usually RFA is followed by an high dose proton pump inhibitor (PPI) therapy. Recent evidence indicates that the combination of RFA and effective fundoplication increases the yield of the first RFA session to eliminate NDBE from 70 % to more than 90 %. Conceptually, the epidemiological characteristics and the genetic insecurities of NDBE, which are comparable to those of the advanced stages of the disease (dysplasia and cancer) justify RFA of NDBE for cancer prevention.
This chapter addresses the role of RFA and fundoplication for the “causal” management of GERD and NDBE. In addition, RFA and anti reflux surgery should consider our novel understanding of the anatomy and the histopathology of the esophagogastric junction (i.e. squamo-oxyntic gap; dilated distal esophagus). The majority of esophageal adenocarcinomas are missed by current surveillance strategies which focus on the symptomatic NDBE. Consequently we reason the impact of RFA for the elimination of asymptomatic NDBE.
Non dyplastic Barrett’s esophagus (NDBE) results from gastroesophageal reflux and harbors the same cancer risk like a colon polyp (0.5 % annual risk).
RFA is a new endoscopic therapy for effective and durable removal of NDBE.
The biological characteristics and diagnostic insecurities of NDBE justify the removal by RFA.
The article summarizes why RFA should be done at the stage of NDBE and why we should not wait until the development of dysplasia and cancer.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Spechler SJ, Fitzgerald RC, Prasad GA, Wang KK (2010) History, molecular mechanism, and endoscopic treatment of Barrett’s esophagus. Gastroenterology 138(3):854–869
Mueller J, Werner M, Stolte M (2004) Barrett’s esophagus: histopathologic definitions and diagnostic criteria. World J Surg 28(2):148–154
Chandrasoma P, Wijetunge S, DeMeester S et al (2012) Columnar-lined esophagus without intestinal metaplasia has no proven risk of adenocarcinoma. Am J Surg Pathol 36(1):1–7
Ringhofer C, Lenglinger J, Izay B et al (2008) Histopathology of the endoscopic esophagogastric junction in patients with gastroesophageal reflux disease. Wien Klin Wochenschr 120(11):350–359
Lenglinger J, Izay B, Eisler M et al (2009) Barrett’s esophagus: size of the problem and diagnostic value of a novel histopathology classification. Eur Surg 41(1):26–39
Triadafilopoulos G (2008) Proton pump inhibitor in Barrett’s esophagus: pluripotent but controversial. Eur Surg 40(2):58–65
Tamhankar AP, Peters JH, Portale G et al (2004) Omeprazole does not reduce gastroesophageal reflux: new insights using multichannel intraluminal impedance technology. J Gastrointest Surg 8(7):890–897
Theisen J, Peters JH, Fein M et al (2005) The mutagenic potential of duodenoesophageal reflux. Ann Surg 241:63–68
Fein M, Peters JH, DeMeester TR (2007) Carcinogenesis in reflux disease: in search for bile-specific effects. Microsurgery 27(8):647–650
Koch OO, Kaindlsdorfer A, Antoniou SA et al (2012) Laparoscopic Nissen versus Toupet fundoplication: objective and subjective results of a prospective randomized trail. Surg Endosc 26(2):413–422, Epub 2011 Sep 5
Vallböhmer D, DeMeester SR, Oh DS et al (2006) Antireflux surgery normalizes cyclooxygenase-2 expression in squamous epithelium of the distal esophagus. Am J Gastroenterol 101(7):1458–1466
Fleischer DE, Odze R, Overholt BF et al (2010) The case for endoscopic treatment of non-dysplastic and low grade dysplastic Barrett’s esophagus. Dig Dis Sci 55:1918–1931
Spechler SJ (2007) Screening and surveillance for Barrett’s esophagus – an unresolved dilemma. Nat Clin Pract Gastroenterol Hepatol 4(9):470–471
Zaninotto G, Parente P, Salvador R et al (2012) Long term follow up of Barrett’s epithelium: medical versus antireflux surgical therapy. J Gastrointest Surg 16(1):7–14; discussion 14–15. Epub 2011 Nov 16
Dulai GS, Guha S, Kahn KL et al (2002) Preoperative prevalence of Barrett’s esophagus in esophageal adenocarcinomas: a systematic review. Gastroenterology 122:26–33
Rieder F, Biancani P, Harnett K et al (2010) Inflammatory mediators in gastroesophageal reflux disease: impact on esophageal motility, fibrosis, and carcinogenesis. Am J Physiol 298:G571–G581
Chandrasoma PT (2006) Columnar lined esophagus: what it is and what it tells us. Eur Surg 38(3):197–209
Lenglinger J, Eisler M, Wrba F et al (2008) Update: histopathology-based definition of gastroesophageal reflux disease and Barrett’s esophagus. Eur Surg 40(4):165–175
Castillo D, Puig S, Iglesias M et al (2012) Activation of the BMP-4 pathway and the early expression of CDX2 characterize non-specialized columnar metaplasia in a human model of Barrett’s esophagus. J Gastrointest Surg 16(2):227–237; discussion 237. Epub 2011 Nov 11
Huo X, Zhang HY, Zhang XI et al (2010) Acid and bile salt-induced CDX2 expression differs in esophageal squamous cells from patients with and without Barrett’s esophagus. Gastroenterology 139(1):194–203
Arora G, Basra S, Roorda AK, Triadafilopoulos G (2009) Radiofrequency ablation for Barrett’s esophagus. Eur Surg 41/1:19–25
Shaheen NJ, Sharma P, Overholt BF et al (2009) Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 360:2277–2288
Shaheen NJ, Overholt BF, Sampliner RE et al (2011) Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia. Gastroenterology 141:460–468
Fleischer DE, Overholt BF, Sharma VK et al (2008) Endoscopic ablation of Barrett’s esophagus: a multicenter study with 2.5-year follow up. Gastrointest Endosc 68(5):867–876
Lyday WD, Corbett FS, Kuperman DA et al (2010) Radiofrequency ablation of Barrett’s esophagus: outcomes of 429 patients from a multicenter community practice registry. Endoscopy 42:272–278
Fleischer DE, Overholt BF, Sharma VK et al (2010) Endoscopic radiofrequency ablation for Barrett’s esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy 42(10):781–789
Pouw RE, Gondrie JJ, Rygiel AM et al (2009) Properties of the neosquamous epithelium after radiofrequency ablation of Barrett’s esophagus containing neoplasia. Am J Gastroenterol 104(6):1366–1373
Beaumont H, Gondrie JJ, McMahon BP et al (2009) Stepwise radiofrequency ablation of Barrett’s esophagus rpeserves esophageal inner diameter, compliance, and motility. Endoscopy 41(1):2–8
Inadomi JM, Somsouk M, Madanick RD et al (2009) A cost-utility analysis of ablative therapy for Barrett’s esophagus. Gastroenterology 136(7):2101–2114
Gray NA, Odze RD, Spechler SJ (2011) Buried metaplasia after endoscopic ablation of Barrett’s esophagus: a systematic review. Am J Gastroenterol 106(11):1899–1908
Wani S, Puli SR, Shaheen NJ et al (2009) Esophageal adenocarcinoma in Barrett’s esophagus after endoscopic ablative therapy: a meta-analysis and systemic review. Am J Gastroenterol 104:502–513
Takubo K, Aida J, Naomoto Y et al (2009) Cardiac rather than intestinal type background in endoscopic resection specimens of minute Barrett adenocarcinoma. Hum Pathol 40(1):65–74
Rubenstein JH, Scheiman JM, Sadeghi S et al (2011) Esophageal adenocarcinoma incidence in individuals with gastroesophageal reflux: synthesis and estimates from population studies. Am J Gastroenterol 106(2):254–260
Ayazi SH, Tamhankar A, DeMeester SR et al (2010) The impact of gastric distension on the lower esophageal sphincter and its exposure to acid gastric juice. Ann Surg 252(1):57–62
Lord RVN, DeMeester SR, Peters JH et al (2009) Hiatal hernia, lower esophageal sphincter incometence, and effectiveness of Nissen fundoplciation in the spectrum of gastroesophageal reflux disease. J Gastrointest Surg 13(4):602–610
Lagergren J, Bergström R, Lindgren A et al (1999) Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Eng J Med 340(11):825–831
Mabrut JY, Baulieux J, Adham M et al (2003) Impact of antireflux operation on columnar lined esophagus. J Am Coll Surg 196(1):60–67
Gurski RR, Peters JH, Hagen JA et al (2003) Barrett’s esophagus can and does regress after antireflux surgery: a study of prevalence and predictive features. J Am Coll Surg 196(5):706–712
Csendes A, Braghetto I, Burdiles P et al (2009) Late results of the surgical treatment of 125 patients with short-segment Barrett esophagus. Arch Surg 144(10):921–927
Chang EY, Morris CD, Seltman AK et al (2007) The effect of antireflux surgery on esophageal carcinogenesis in patients with Barrett esophagus: a systematic review. Ann Surg 246(1):11–21
Lagergren J, Ye W, Lagegren P, Lu Y (2010) The risk of esophageal adenocarcinoma after antireflux surgery. Gastroenterology 138(4):1297–1301
Hubbard N, Velanovich V (2007) Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus in patients with fundoplication. Surg Endosc 21:625–628
dos Santos RS, Bizekis C, Ebright M et al (2010) Radiofrequency ablation fro Barrett’s esophagus and low grade dysplasia in combination with antireflux procedure: a new paradigm. J Thorac Cardiovasc Surg 139(3):713–716
O’Connell K, Velanovich V (2011) Effects of Nissen fundplication on endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus. Surg Endosc 25(3):830–834
Goers TA, Leao P, Cassera MA et al (2011) Concomitant endoscopic radiofrequency ablation and laparoscopic reflux operative results in more effective and efficient treatment of Barrett’s esophagus. J Am Coll Surg 213(4):486–492
Korst RJ, Santana-Joseph S, Rutledge JR et al (2011) Effect of hiatal hernia size and columnar segment length on the success of radiofrequency ablation for Barrett’s esophagus: a single-center, phase II clinical trial. J Thorac Cardiovasc Surg 142(2):1168–1173
Chandrasoma P, Wijetunge S, Ma Y, DeMeester S et al (2011) The dilated distal esophagus: a new entity that is the pathologic basis of early gastroesophageal reflux disease. Am J Surg Pathol 35(12):1873–1881
Chandrasoma P, Wijetunge S, DeMeester SR et al (2010) The histologic squamo-oxyntic gap: an accurate and reproducible diagnostic marker of gastroesophageal reflux disease. Am J Surg Pathol 34(11):1574–1581
Wijetunge S, Ma Y, DeMeester S et al (2010) Association of adenocarcinoma of the distal esophagus, “gastroesophageal junction”, and “gastric cardia” with gastric pathology. Am J Surg Pathol 34(10):1521–1527
Siewert JR, Stein HJ, Feith M (2006) Adenocarcinoma of the esophago-gastric junction. Scand J Surg 95(4):260–269
Theisen J, Stein HJ, Feith M et al (2006) Preferred location for the development of esophageal adenocarcinoma within a segment of intestinal metaplasia. Surg Endosc 20(2):235–238
Corley DA, Levin TR, Habel LA et al (2002) Surveillance and survival in Barrett’s adenocarcinomas: a population based study. Gastroenterology 122:633–640
Hvid-Jensen F, Pedersen L, Mohr Drewes A et al (2011) Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 365:1375–1383
Gerson LB, Shetler K, Triadafilopoulos G (2002) Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology 123:461–467
Rex DK, Cummings OW, Shaw M (2003) Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology 125:1670–1677
Rubenstein JH, Mattek N, Eisen G (2010) Age- and sex-specific yield of Barrett’s esophagus by endoscopy indication. Gastrointest Endosc 71(1):21–27
Bonavina L, DeMeester T, Fockens P et al (2010) Laparoscopic sphincter augmentation device eliminates reflux symptoms and normalizes esophageal acid exposure. Ann Surg 252(5):857–862
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2012 Springer-Verlag Italia
About this chapter
Cite this chapter
See, S.F., Schoppmann, S.F., Riegler, M., Zacherl, J. (2012). Radiofrequency Ablation and Antireflux Management for Non-dysplastic Barrett’s Esophagus. In: Bonavina, L. (eds) Innovation in Esophageal Surgery. Springer, Milano. https://doi.org/10.1007/978-88-470-2469-4_5
Download citation
DOI: https://doi.org/10.1007/978-88-470-2469-4_5
Published:
Publisher Name: Springer, Milano
Print ISBN: 978-88-470-2468-7
Online ISBN: 978-88-470-2469-4
eBook Packages: MedicineMedicine (R0)