Barretts Esophagus:

1
Barretts Esophagus What can we see? What can
we do?
Hanns-Ulrich Marschall Karolinska University
Hospital Huddinge Karolinska Institutet
Stockholm
2
Los Angeles classification of esophagitis
LA grade A
LA grade B
1 cm
1 cm
LA grade C
LA grade D
1 cm
1 cm
Lundell et al. Gut 199945172-80.
3
The Prague C M criteria of Barretts
16
14
12
Distance in cm from gastro- oesophageal junction
10
8
6
4
2
0
Sharma et al. Gastroenterology 20021311392-99.
4
The Prague C M criteria of Barretts
C0 M5
Sharma et al. Gastroenterology 20021311392-99.
5
Real Chromoendoscopy
Methylen blue Highly contradictory
results Indigo carmine Insufficient
data Acetic acid Easy, quick
Pech. Clin Gastroenterol Hepatol. 20097610-12.
6
Virtual Chromoendoscopy
NBI Narrow Band Imaging
7
Virtual Chromoendoscopy
FICE
i-SCAN
8
conventional vs. NBI better with NBI
white light, random biopsies NBI, targeted
biopsies Dysplasia 28/65 (43) plt0.01 37/65
(57) Higher grade of dysplasia 0 12/65
(18) Biopsies 8.5 plt0.01 4.7
Wolfsen et al. Gastroenterology 2008134670-9.
9
conventional vs. HDNBI its HD that counts!
Wolfsen et al. Gastroenterology 2008134670-9.
10
HD white light /- NBI no better with NBI
Curvers et al. Gastroenterology 2008134670-9
Endoscopy 200840799-805 GI Endosc
200969307-17.
11
Randomized Cross-Over Trial
HD white light endoscopy 4 quadrant biopsies q 2
cm
116 Barretts patients Kansas City Charleston
Amsterdam 94 men Average age 59 years Average
Barretts C1.9 M3.6
6-8 weeks later
NBI mucosal patterns targeted biopsies
Sharma et al. DDW 2009
12
Randomized Cross-Over Trial
plt0.0001
p0.0002
Sharma et al. DDW 2009
13
NBI with magnification better than WL
Curvers et al. Gastroenterology 2008134670-9
Endoscopy 200840799-805 GI Endosc
200969307-17.
14
Narrow Band Imaging with Magnification
ridge/villous
circular
irregular/distorted
IM without HD sensitivity 93.5 specificity
86.7
HD sensitivity 100 specificity 98.7
no difference
low-grade dysplasia
high-grade dysplasia
intestinal metaplasia
Sharma et al. Gastrointest Endosc 200664167-75
15
Narrow Band Imaging with Magnification
Three classification systems Kansas
City-Amsterdam-Nottingham
Silva et al. submitted
16
HD Autofluorescence NBI
Kara et al. Endoscopy 200638627-31.
17
Confocal Imaging
250 µm
475 µm
475 µm
Optical Resolution, lateral and axial lt1µm
18
Confocal Imaging
Scope Probe Dye
Fluorescein i.v. Fluorescein i.v.
(Acriflavin topically) Magnification 1000x 1
000x Image depth zoom 0-250 µm fixed 40-70
µm Resolution 1 µm 1 µm Frame
rate 0.8/s 12/s
19
Confocal Imaging Scope
BE sensitivity 98.1 specificity 94.1
HD sensitivity 92.9 specificity 98.4
Kiesslich et al. Clin Gastroenterol Hepatol.
20064979-87.
20
Confocal Imaging Probe
HD/early cancer
BE
HD sensitivity 75.0 specificity 89.9
Pohl et al. Gut. 2008571648-53.
21
Take home messages
Take the best endoscope you have Look longer,
biopsy less NBI is not a detection technique in
BE AFI CE are experimental
22
How to define a low-risk lesion? By
endoscopic appearance use your best
endoscope By endoscopic ultrasound
use low highest resolution By endoscopic
resection ER is diagnostic! but ask for
second opinion
23
Surgery Endoscopic Resection Morbidity
18-48 Morbidity 1-3 Mortality
2-20 Mortality 0 Low risk of
lymph-node metastasis in low-risk mucosal
carcinomas (0 in Barretts cancer
0-10 in squamous cell cancer) Reduced quality
of life Organ preservation, quality of life
not compromised
Pech et al. Gut 2007561625-34.
24
Paris Classification Type 0 (superficial) Low
risk Barretts types I and II
protruding I nonprotruding and nonexcavated
II excavated (III) slightly elevated (IIa),
flat (IIb), depressed (IIc)
X
Endoscopic Classification Review Group.
Endoscopy. 200537570-8.
25
Lymphnode involvement Low risk 0-5
Barretts cancer squamous cancer
m1
X
m2
X
m3
sm1
sm2
sm3
Pech et al. Gut 2007561625-34.
26
All Barretts HGIN and IMC
All patients presenting 1996-2002 486 with
Barretts neoplasia treated endoscopically 349
high-grade intramucosal neoplasia
61 intramucosal adenocancer 288 short-segment
BE 173 long-segment BE 176
Pech et al. Gut 2008571200-6.
27
All Barretts HGIN and IMC
Endoscopic resection (ER) 279 Photodynamic
therapy (PT) 55 ER PT 13 Argon Plasma
Coagulation (APC) 2
Complete response 337 (96.6) Surgery 13
(3.4)
Pech et al. Gut 2008571200-6.
28
All Barretts HGIN and IMC
Follow-up 63.6 23.1months Metachronous
lesions 74 (21.5) patients Barrettcancer
deaths 0 5-year survival 84 (average
German)
Pech et al. Gut 2008571200-6.
29
NIH Surveillance Epidemiology and End Results
Early oesophageal cancer 742 patients
Surgery 643 patients Endoscopic
treatment 99 patients (65 EMR
only) Equivalent long-term survival
Das et al. Am J Gastroenterol. 2008 1031340-5.
30
Update guidelines of the American College of
Gastroenterology for the diagnosis, surveillance
and therapy of Barretts esophagus Indications
for definite endoscopic treatment In
general - Unifocal, limited size ( 2 cm) -
Mucosal, no local lymphnodes involved -
Well/moderately differentiated neoplasia Relativ
e - Size gt 2 cm (piece meal resection) -
(minimal) mucosal invasion - Less well
differentiated lesions Esophagectomy is no
longer the necessary treatment response to HGD.
Wang et al. Am J Gastroenterol 2008103788797.
31
Endoscopic mucosal resection EMR Piecemeal ER
with MBM faster and cheaper MBM preferred
for flat lesions ER-Cap preferred for
isolated elevated or nodular lesion
Multiband Mucosectomy MBM
suck-and-cut technique
Pouw et al. Gut 2008 57 (Suppl II) A 83.
32
Endoscopic submucosal dissection ESD
En bloc competes with MBM for total
resection Advantage at cardia?
Seewald et al. Endoscopy. 2008401016-20.
33
Total resection
High risk for significant strictures
Total ablation
High risk for significant strictures with APC,
PDT Low risk for significant strictures with
BÂRRX
BÂRXX HALO90 /HALO360 Ablation Catheters
BÂRXX HALO360 Sizing Balloon
34
Bipolar electrode
35
Radiofrequency ablation in BE with dysplasia
Shaheen N et al. New Engl J Med 20093602277-88.
36
Take home messages
Careful endoscopic examination detects early
malignancy that successfully can be treated
endoscopically, which makes Barrettss
surveillance useful.