Treatment of Barrett esophagus using miniinvasive operations

Barrett esophagus is a precancer condition, the course is without symptoms, is found out by chance during gastroscopic investigation.

N.Barrett was the first who described the cylindric epithelium in esophagus in 1950, but he was mistaken telling that it was congenital shortened esophagus. Then, in 1953 P.Allison and A.Johnstone found out that described changes were referred to the mucous membrane of esophagus and were the consequence of replacement of plane epithelium by cylindric one. Then, in 1970 C.Bremner demonstrated arising of cylindrocellular metaplasia of esophageal epithelium in case of gastroesophageal reflux, caused artificially while doing experiments with animals, having proved the acquired character of those changes and relation to hiatal hernia or GERD (gastroesophageal reflux disease).

Spreading of esophageal metaplasia among Europeans according to different data varies within the range 2-5% . At the same time, if GERD is present, either alongside with the hiatal hernia, or without it, cylindric cellular metaplasia of the mucous membrane of esophagus is diagnosed in 10-15 % of patients. Adenogenous cancer of esophagus, developed on the background of metaplasia, was first described by B.Morson and J.Belcher in 1952, and in 1975 A.Naef based theoretically the development of adenocarcinoma from esophageal epithelium, affected by metaplasia. Esophageal adenocarcinoma is a lethal disease, and there is only 5-year survival after operation, and in less than 20% of patients. And in Russia it is diagnosed at the late stages. In those patients, who have Barrett esophagus, the risk of tumour lesion is 30-120 times higher.

In 1983 D.Skinner proved the presence of pathogenetic chain on the basis of extensive clinical material: gastroesophageal reflux ---cylindric cellular metaplasia—adenogenous cancer of esophagus.

Facts, described above, makes us consider cylindrocellular metaplasia of the mucous membrane of esophagus to be an important surgical problem that requires serious approach to solve it.

The use of correct and contemporary algorhythm in treatment of gastroesophageal reflux disease that has development of cylindrocellular metaplasia of esophagus in its course, gives a possibility not only to improve quality of life of a patient, but to prevent development of adenocarcinoma of esophagus, using surgical endoscopic techniques.

Diagnostics of Barrett esophagus.

Barrett esophagus is diagnosed in case of endoscopic investigation of esophagus and stomach.Investigation is performed, using a videoesophagogastroscope with NBI or chromoscopy with biopsy taking not less than from 4 areas. Histological or immunohistochemical investigation of preparations is done. Visually in the lower one-third of esophagus one can see changes of mucous membrane-the colour is bright red, like flames.

The height of changes of the mucous membrane (the length of Barrett esophagus) can be of 3 types: short-when the length of the affected part is less than 3 cm, of a medium length-3-5 cm, and long-more than 5 cm. It is very important to understand the degree and kind of displastic changes in the changed mucous membrane (classification according to P.H.Riddel) (1983).

I would like to attract your attention that in order to examine such a delicate zone as the lower one-third of the esophagus and cardial part of stomach, assessment of condition of gastroesophageal isthmus and function of the inferior esophageal sphincter, it is necessary that a patient should be in a quiet condition, there should be absence of antiperistaltic contraction due to the vomiting reflex. As many authors say, total “intralumen calm on board the ship is required, when there is storm in the ocean”. That is why the use of short intravenous sedation gives a possibility to a patient to overcome this procedure, and a doctor will be able to obtain more exact results and to make up the proper diagnosis. In our clinic we use videofibroscopy and anesthetics, made in the U.S.A.

During the latest period histologists have come to the conclusion that material, taken from one and the same area of Barrett esophagus, can correspond to different kinds of dysplasia: intestinal metaplasia, gastric metaplasia or cardial type of metaplasia. Thus, in one and the same part of esophagus 2 or 3 types of epithelium can be met. It happens as a result of pathologic reflux of aggressive contents of stomach into the esophagus (either bile, or acid) and consecutive transition of esophageal epithelium first into the cardial type, then-into intestinal one. And this kind of situation is met in 30 % of patients. It is important to understand-and it has been based on many investigations-that the kind of dysplasia does not influence turning it into cancer. That is why the indication for operation is presence of Barrett esophagus, if this fact has been proved. And it does not depend on kind and stage of dysplasia.

We should mark that Barrett esophagus develops in 70 % of cases on the background of hiatal hernia and GERD without hiatal hernia. That is why in order to make up the proper diagnosis and to understand the development of this condition, we should have maximum information about the condition of the superior part of the GIT. For this purpose it is necessary to perform esophagogastroscopy, during this procedure it is necessary to assess the condition of the mucous membrane of esophagus and stomach, take material for biopsy from several areas (areas of changes) and determine the length of changed mucous membrane of esophagus in cm, and try to find bile in stomach and estimate the condition of pylorus. Then it is necessary to perform daily Ph-metry of esophagus and stomach in order to understand the kind of reflux: acid or alkaline. Then it is necessary to do X-ray investigation of esophagus and stomach during which you can either confirm, or reject the diagnosis “hiatal hernia” and analyse evacuation from stomach and find out duodenostasis, and to determine its degree, if it is present.

This information is the basis when choosing the algorhythm of individual treatment for some patient.

Treatment of Barrett esophagus, using miniinvasive techniques: laparoscopy and endoscopy.

It is worthy to mention that only in case of total investigation we can obtain much information about a patient. If Barrett esophagus due to endoscopic investigation has been found out and if it has been histologically testified, it should be compulsory treated , as there is risk that cancer may develop.

At this stage the results of cytological and histological investigations will help us to choose the method of surgical treatment. We have already mentioned that Barrett esophagus is characterized by hyperkeratic, metaplastic and dysplastic changes of the mucous membrane of esophagus. Thus, if we find out hyperkeratosis, gastric metaplasia and metaplasia of small and large intestines, dysplasia of mild and moderate severity, we are talking about benign process. In case of dysplasia of severe degree or if squamous cell nonkeratinous carcinoma is found out, the diagnosis is: oncological disease. It gives us a possibility to use 2 kinds of treatment-in the first case-organ-preserving treatment, and in the second case-removal of organ (operation according to Lewis).

Immunohistochemical investigation, alongside with the histological investigation of biopsy material, give us a possibility to find out early forms of adenocarcinoma of esophagus. Esophageal cancer is characterized by increase of the square of expression of Ki-67 marker and antiapoptosous factor bci-2 as compared to values in case of gastroesophageal reflux disease and Barrett esophagus. Thus, differentiated diagnostics of Barrett esophagus and adenocarcinoma of esophagus can be achieved due to study of the results of immunohistochemical investigation of esophageal cells, that are producing synthase of nitrogen oxide and endothelin-1.

If, as a result of performed endoscopic investigatioin, histological and immunohistochemical investigations dysplasia of severe degree and adenocarcinoma of esophagus have not been found out, we should talk about organ-preserving treatment of Barrett esophagus. The stages of this algorhythm will be described by me below.

In case of absence of hiatal hernia. especially for young patients, we use radiofrequency ablation of Barrett esophagus. After operation we administer therapy by blockers of proton pump (to supress gastric secretion) and motilium (improves gastric motor activity) for 6-8 weeks. Within several months dynamic follow-up takes place. If relapse happens, this procedure can be repeated again, as we influence only the mucous membrane, not injuring the whole of the esophageal wall.

If there is hiatal hernia, at the first stage it is necessary to perform on surgery-laparoscopic fundoplication according to Toupe (bilateral fundoplication-270 degrees) and cruroraphy. This interference removes hernia and stops pathological reflux of aggressive contents of stomach into esophagus. Without this stage treatment of Barrett esophagus does not give positive results. After operation therapy by blockers of proton pump is administered for 3-4 months.

This stage gives a possibility in 90 % of cases to stop pathological reflux into esophagus and in this way to stop pathological transformation of mucous membrane.

After operation in 2-3 months it is necessary to perform radiofrequency ablation of affected mucous membrane, and to examine esophagus (FGI) in 3 and 6 months. In case of positive dynamics further follow-up is done once or twice a year.

Some patients, having big changes in the length of mucous membrane (the long segment of Barrett esophagus) , require radiofrequency ablation 1-2 times a year.

If in case of repeated examination of mucous membrane its condition is better, the further dynamic follow-up should be continued, FGI is done with the interval 6 months. In a year the final assessment is done: whether a patient has Barrett esophagus or not. In most patients Barrett esophagus is developed in reversed way (especially in patients with hiatal hernia and having acid reflux). If morphologically, during biopsy, we see that changing of mucous membrane continues (metaplasia is still present), then we proceed to the next stage-endoscopic or argon-plasmatic coagulation of mucous membrane of esophagus in the area of Barrett esophagus.

Radiofrequency ablation and argon-plasmatic coagulation are done under the guidance of an endoscope, as a rule, using general anesthesia (short intravenous sedation). If the segment of lesion is not more than 3 cm, it is enough to do it once. If it is more than 3 cm, there is sometimes necessity to do it twice. In case of radiofrequency ablation the affected tissue is replaced by plane epithelium and is healed without scars. We prefer to resort to radiofrequency ablation, it is the improved version of argonplasmatic coagulation, as it has less side-effects.

One should bear in mind that if in the area of metaplasia there are areas of neoplasia of high degree, where the probability of invasive growth is considerably increased, radiofrequency ablation is also possible. In case of deep lesions endoscopic radical removal of the area of mucous membrane of esophagus is done. If the square of changes is less than 2 sq.cm, as a rule, endoscopic resection of mucous membrane of esophagus is done (EMR-C), but if the square is more than 2 sq.cm-then dissection in submucous layer (ESD) is performed.

Then follow-up of a patient until his death is performed-within the first year-in 3 months, then-once a year FGI is done with the possible biopsy of mucous membrane in suspected areas.

Relapse of Barrett esophagus develops very rarely (less than 5%) after this kind of treatment stage by stage. As a rule, it develops in case of relapse of hiatal hernia and if there are remnants of changed mucous membrane after RFA (radiofrequency ablation).

Some surgeons treat in a reversed order-first RFA, then-laparoscopic fundoplication. It should be noticed that the best time of laparoscopic esophageal operation is 3-4 months later after the first stage. So, according to USI of esophagus data walls remain edematic for a long time (on the background of RFA). That is why performing on fundoplication at early period can promote development of stenosis in the area of gastroesophageal isthmus. Naturally, that healing of mucous membrane of esophagus will be longer as reflux of aggressive contents from stomach remains not corrected. That is why we, while working, use clever consecutive order. First comes pathogenetic stage to stop reflux, and only then –RFA. As I have mentioned above, for some patients the second stage is not required, as mucous membrane becomes normal due to healing processes.

Thus, at the first stage laparoscopic fundoplication gives a possibility to decrease the size of affected segment of esophagus, and RFA will be required only once, and there will be lesser risk of stricture development in esophagus, and in some patients the second stage will be absent at all.

If you want to make an appointment with the doctor,

please, call the tel: +7 495 222-10-87 +7 903 798-93-08 Olga - that is my assistant.

Or you may use my e-address: puchkovkv@mail.ru puchkovkv@mail.ru copy

«When you write me letters, you should be sure that all of them will find themselves in my e-mail. I always reply your letters myself. I remember that you trust me the most precious things - your health, your fate, your family, your nearest and dearest, and I always try to do my best to justify your trust.

Every day I answer your letters, and it takes me several hours.

When you write me letters, you can be sure, that I will learn your situation very attentively, in case of need I will ask for some additional medical documents.

A great clinical experience and thousands of successful operations will give me a possibility to understand your problem even at some distance. Many patients need not surgical treatment, but properly administered conservative treatment, but some patients need urgent surgery. In both cases I would recommend additional investigations in case of need or admitting to hospital. It is important to bear in mind that some patients need preliminary treatment of accompanying diseases in order to have a successful operation.

In your letter, please, mention your age, main complaints, your place of residence, telephone number and e-mail.

For me to be able to give you a full answer, please, forward me a scanned conclusion of USI, CT, MRT alongside with your question, as well as conclusions of other specialists. After studying your case I will forward you either my detailed reply, or a letter with some additional questions to clarify the situation. Anyhow, I will try to help you and justify your hope and trust that are the most important things for me.

Sincerely, your

surgeon Konstantin Puchkov»