Barrett’s Oesophagus and Barrett’s Mucosa
Gastro-oesophageal reflux disease or GORD is a chronic condition in which acid leaks from the stomach into the oesophagus. The symptoms can usually be controlled with diet and medication, although surgery is sometimes required to relieve severe acid reflux. If GORD symptoms persist for a long time it can lead to complications such as Barrett’s oesophagus so it is important to seek treatment if you have chronic reflux. Managing the symptoms can help to prevent the following complications.
Scarring of the Oesophagus
If the lining of your oesophagus is repeatedly exposed to stomach acid, it can become damaged and scarred. Severe scarring can even make the oesophagus narrower than usual, which can make it harder to swallow. If you are experiencing difficulty or discomfort when swallowing, your doctor mat recommend a procedure to widen your oesophagus.
The damage caused by repeated exposure to stomach acid can also cause ulcers to develop in the oesophagus. Ulcers are painful sores that may bleed a little. They can make it very uncomfortable to eat. The best way to manage ulcers is to take medication to prevent acid reflux, which should give the ulcers a chance to heal.
Barrett’s Oesophagus and Oesophageal Cancer
Another potential complication caused by stomach acid escaping the stomach is Barrett’s oesophagus. It happens when the lining of your oesophagus changes into a different type of cell. If this happens, it can increase the chances of developing oesophageal cancer. The abnormal cells may need to be checked regularly with an endoscopy or removed to prevent them from becoming cancerous. Most people who have GORD and Barrett’s oesophagus won’t be affected by oesophageal cancer, but the risk is higher than normal. It is therefore important to follow your doctor’s advice on treatment and screening.
All of these potential complications of GORD are caused by repeated exposure of the oesophagus to stomach acids. It is therefore possible to prevent these problems by having GORD treatment to prevent the stomach acid from escaping. In most cases it will be possible to control your acid reflux with medication, but sometimes it is necessary to perform surgery in order to protect your oesophagus.
Barrett’s Oesophagus Dysphagia and Stricture
GERD symptoms in Barrett’s oesophagus patients
Although GERD symptoms (gastroesophageal reflux disease symptoms) occur in about 10% of the general population on a daily basis, complications are much less common.
People with Barrett’s oesophagus generally have much worse reflux than the average sufferer. What does this mean?
Reflux means bringing the contents from the stomach back up into the oesophagus.
Most people without Barrett’s disease only reflux stomach contents, particularly acid and pepsin (digestive enzymes which help break down the food).
People with Barrett’s frequently reflux more. This includes contents of the bowel as well as the stomach. These contents include bile and pancreatic juices. They are powerful and can destroy almost any food.
The stomach has a strong lining, which is covered with a thick mucus layer. It is relatively unaffected by these juices but it is no wonder they cause problems if they get into the oesophagus!
People with Barrett’s may get very bad reflux, but they get less symptoms than other people. We think the Barrett’s lining somehow protects people from the sensation of reflux. In fact, most people with Barrett’s never even realise they have it.
So when a person with Barrett’s gets symptoms, it is important to think about complications. It is true that these are relatively unusual, but it is worth knowing what to look out for.
Important complications of Barrett’s
Dysplasia (pre-cancerous change)
Remember what Barrett’s Oesophagus is:
Oesophagitis means inflammation of the gullet. Remember that Barrett’s oesophagus is a change in the type of cells lining the gullet. This usually affects the bottom of the gullet only and may vary in length from 1 to 20cm! In most people this change affects a length of less than 5cm. The Barrett’s lining might be inflamed, but is often not inflamed at all.
Oesophagitis usually occurs at the top end of the Barrett’s lining. Because the reflux is bad, the sufferer may have really quite severe inflammation. Because the Barrett’s lining protects them from symptoms, they may feel quite normal. So if someone gets new onset or worsening heartburn, it is quite likely that the oesophagitis will be rather severe.
Oesophagitis will usually respond to acid suppression medicines but some people will need more intensive therapy.
If oesophagitis is not properly treated, the area may start to become scarred. Extensive scarring will cause a stricture or narrowing to develop. This is uncommon now as the proton pump inhibitor drugs have more or less solved this problem for most people.
If a Barrett’s sufferer becomes aware that food is sticking in the chest, however, there is a chance that a stricture has formed.
Increasing acid suppression treatment might help treat the stricture, but in many cases, the narrowed area will need to be stretched by the doctor.
Acid Reflux Attacks
An acid reflux attack can be really unpleasant, particularly if you have never had one before. At its worst, it resembles a heart attack, with severe central chest pain which goes up into the shoulder. If this happens, you need to go to hospital to be checked. If it is less severe, it can still cause bad heartburn, chest pain, or nausea and even vomiting.
Chest pain due to acid reflux attacks can be almost impossible to distinguish from a heart attack and if it is severe, it needs to be treated very seriously. Nevertheless, there are a few tell-tale signs that the problem is due to digestion.
First: have you just eaten a large or fatty meal? (more likely reflux)
Second: are you young and fit ?
Third: can you usually do vigorous exercise? (more likely reflux)
Fourth: have you suffered with indigestion in the past? (more likely reflux)
Fifth: did the pain come on after exercise? (more likely heart)
Sixth: are you also breathless? (more likely heart)
You may need a heart tracing (ECG) or blood tests to be able to distinguish chest pain due to reflux (also called ‘atypical chest pain’) from a heart attack. If you have chest pains which you are worried about, please call your doctor urgently for advice.
This is the most typical symptom of an acid reflux attack. Heartburn is a burning sensation which starts in the pit of the stomach, just below the bottom of the breastbone, and rises through the chest. It is typically brought on by eating, particularly large or fatty meals. It may also be caused by exercise or bending forward.
Waterbrash and Choking
Waterbrash means bringing a bitter or acidic tasting fluid into the back of the mouth. Once again, this particularly happens after eating, exercising or bending forward. If it happens at night, the acidic fluid can go into the lungs. This causes a terrible feeling of choking which can last for a minute or two before subsiding. This choking feeling is never fatal but it is very unpleasant. Fortunately, there are good treatments to prevent this occurring. Indeed, this symptom is the one which tends to respond best to antireflux surgery.
Dysphagia means difficulty swallowing. There are many causes but if solid foods get stuck somewhere in the throat or chest before reaching the stomach, this can be due to acid reflux. It can, however, be a sign of oesophageal cancer, so you should see a specialist urgently if this occurs.
An on-going intermittent cough can be due to acid reflux and can actually be the only sign a person has the condition. A reflux related cough responds well to medicines although for some people it can take quite a long time to resolve.
One of the really strange effects of an acid reflux attack is that it can cause the voice to become hoarse.
If the reflux attack occurs in the middle of the night, the person may not even realise it has happened. Instead, they wake up with a hoarse voice which can last for a few days.
If these reflux attacks occur frequently, a person can have a hoarse voice which never gets better. This needs proper investigation and specialised treatment to cure because acid reflux attacks, which present in this way are very difficult to detect.
Do you want more information? Would you like an expert opinion?
Why not have a private consultation with one of our Barrett’s experts. Please tell our staff that you want to see a consultant who specializes in this condition. We will ensure you see the right doctor.
Barrett’s Progression to Cancer
Progression to High Grade Dysplasia & Oesophageal Cancer
Are you worried about the risk of progression to oesophageal cancer in Barrett’s oesophagus?
The real risk of Oesophageal Cancer in Barrett’s Oesophagus
Over the last few years, large numbers of scientific studies have focused on this point. Since 2010, three big studies have shown that the likelihood of getting oesophageal cancer is no more than 0.36% per year. This means that the average person with Barrett’s would need to live for 300 years before they got cancer!
Major Risk Factors
The single most important risk factor for developing oesophageal cancer is the presence of dysplasia.
What is dysplasia?
This word is derived from a Greek word. It means “bad formation”.
The word dysplasia is used when the cells have changed abnormally, and may in some cases progress to cancer. Dysplasia is the earliest form of pre-cancerous change that can be recognized and may be rated as either low grade or high grade, the latter representing a more advanced progression towards cancer.
Dysplasia is found when samples from the Barrett’s oesophagus are examined under the microscope. These biopsy samples are taken during an endoscopy examination. Many people with Barrett’s oesophagus undergo routine surveillance endoscopy.
Low Grade Dysplasia (LGD)
Almost one in ten people with Barrett’s oesophagus will develop low grade dysplasia (LGD) at some point over the years. Most of these people will never get cancer.
The trick is to work out who is at high risk of progressing to cancer.
There are some simple ways to do this and some ways that are a little more complex.
The simplest thing to do is to confirm that LGD actually exists.
Confirm the Presence of Low Grade Dysplasia
Inflammation can easily be mistaken by the pathologist for low grade dyplasia. Inflammation is caused by lots of acid reflux.
It is important to minimise the reflux for 8 weeks before any endoscopy examination. This will reduce the likelihood of ‘over diagnosing’ LGD.
You can reduce the amount of reflux you get by taking extra care with your diet.
You can also reduce reflux by remembering to take all your medicines. If you take the medicines but still get reflux attacks, you might want to increase the dose of your medicines, particularly proton pump inhibitors for a few weeks before having an endoscopy. You should only do this after discussion with your doctor but it is an important way to stop the over diagnosis of LGD.
If the pathologist is convinced that you have LGD, a second pathologist should be asked to confirm the diagnosis. We know that doctors make mistakes in this very tricky area. Indeed, most pathologists do not see enough cases to be certain of what they are seeing. The level of agreement between non-specialist pathologists in this area is very low.
If two expert pathologists confirm LGD, the likelihood of this progressing to cancer rises, although it is probably still less than 20% within 5 years – plenty of time to do something about it!
Nonetheless, it is important to get the diagnosis right. Specialist centres like ours have access to internationally renowned pathologists. Having a world leading pathologist working with out team is really important. It means we can more accurately diagnose the condition.
High Grade Dysplasia (HGD)
The next step towards cancer is high grade dysplasia (HGD).
This is a much more serious finding. Once again, it should be confirmed by at least two specialist pathologists and preferably on at least two separate endoscopies. These are usually done approximately 3 months apart.
If HGD is confirmed, the risk of developing cancer is thought to be about 40% within 5 years. It is now probably time to act, although every case is different.
One thing is certain. If you have HGD, you need to see a specialist who sees this sort of problem regularly. Do not rely on your GP or local gastroenterologist to advise you. NICE (the National Institute for Clinical Excellence) has made it quite clear that this sort of problem needs the help of recognised experts working in centres of excellence.
If you would like to see an overview of the NICE guidelines.
One of the really interesting new areas is the presence of biomarkers. Even high grade dysplasia, the best ‘marker of risk’ only carries a 40% cancer risk at 5 years. Is there anything else to help guide you as to your own cancer risk?
Well, it seems that there may be.
Other recognized markers of risk include
Visible areas of abnormality (nodules) at endoscopy
Specialised tests on cells including
DNA content abnormalities
Changes in cell proliferation markers such as p53, Cyclin A and others
Our own research has shown that analyzing samples taken at endoscopy for these and other markers can more clearly define the risk of progressing to cancer.
This is very helpful because it guides decisions about which treatment to have and when to have it.
For more information on Barrett’s oesophagus, please use the menu below to navigate through our pages
Do you want more information about your own risk of developing oesophageal cancer or high grade dysplasia? Would you like to be assessed for cancer risk biomarkers?
To make an appointment with one of our internationally renowned consultants, please tell our staff that you want to see an expert in cancer risk in Barrett’s oesophagus. We will ensure you see the right person.
Barretts Endoscopic Surveillance in London
Endoscopy Procedure in Barrett’s Oesophagus
Why do an Endoscopy Procedure in Patients with Barrett’s Oesophagus?
Doctors need to know whether a person with Barrett’s oesophagus is at risk of developing cancer. The best way to do this currently is endoscopy – to look inside with a flexible tube which has a video camera built in.
During the endoscopy test, the doctor can take small samples from the lining of the oesophagus. These are called biopsies. The biopsies are sent to the pathologist who will examine them and determine whether dysplasia is developing. Dysplasia is the most powerful sign that an individual is moving along the pathway to developing cancer.
Should People with Barrett’s have Regular Endoscopic Surveillance?
All the major international specialist groups including the British Society of Gastroenterology recommend regular endoscopy for people with Barrett’s oesophagus. The reason is simple. It allows doctors to spot early changes in cells as they move to being cancerous.
Remember – the vast majority of people with Barrett’s oesophagus never actually get cancer. But if they do, early detections means the cancer can still be treated. There is plenty of evidence that people who have regular endoscopies have a higher chance of cure even if they develop cancer.
It is also now possible to treat people before cancer develops. This is only appropriate in some people. It is possible to assess who would benefit from this type of treatment by analysing the biopsy samples taken at endoscopy .
There is some uncertainty, however. Since most people with Barrett’s oesophagus never get cancer, it is not absolutely clear that everyone should have surveillance.
How Often to Survey?
The British Society of Gastroenterology issued new guidance in 2013.
The new guidelines divide sufferers into those with
‘short segment’ Barrett’s (SSBE), where it is less than 3cm long and
‘long segment’ Barrett’s (LSBE) which is more than 3 cm long.
For patients with short segment Barrett’s, they sub-divide into
people with intestinal metaplasia
people without intestinal metaplasia
(They do not divide people with long segment because intestinal metaplasia is present in almost everyone with long segment Barrett’s).
Recommended Surveillance Intervals
- Short Segment Barrett’s Oesophagus, no intestinal metaplasia
- Repeat the endoscopy to confirm the diagnosis
- Discharge from follow up as the cancer risk is so small that the risks of doing repeated endoscopy outweighs the risk of getting cancer
- Short Segment Barrett’s Oesophagus, with intestinal metaplasia
- Regular surveillance endoscopy every 3 to 5 years
- Long Segment Barrett’s oesophagus
- Regular surveillance endoscopy every 2 to 3 years
Who should do the endoscopy procedures?
This should be easy to answer. All gastroenterologists are trained to do endoscopy to a high standard. So are nurse endoscopists. So, surely anyone can do this well?
Well, actually, our experience is that this is simply not true. Endoscopic surveillance of Barrett’s oesophagus is a specialist procedure. Many general endoscopists do not do it particularly well.
Common mistakes doctors can make at endoscopy include:
- Not identifying the Barrett’s oesophagus correctly
- Not taking the right number of biopsies
- Not working with specialist pathologists
- How should it be done?
High quality surveillance requires all of the following:
- Familiarity with Barrett’s
- Someone who sees lots of cases is more likely to detect subtle abnormalities
- The latest endoscopy equipment
- Pre-cancerous changes are subtle. The better the technology used, the more likely tiny abnormalities will be detected.
- Remember, tiny abnormalities today can become rather large abnormalities in a few months time
- Rigorous biopsy protocols
- Most endoscopists do not take many biopsy samples.
- There is excellent evidence that the more biopsies the doctor takes, the more likely they are to find early abnormalities such as dysplasia
- If you are not sure, ask your doctor whether they take quadrantic biopsies (one biopsy in each quarter of the clock face) every 1 or 2 cm throughout the entire length of the Barrett’s
- Another way of asking this is “How long is my Barrett’s?”
- Multiply the answer in your head by 2. So if the Barrett’s is 5cm long, the answer is 10
- Then ask how many biopsy samples the doctor expects to take? If it is less than 10, the doctor is not following the best guidance.
- Advanced Endoscopic Techniques
- There are a number of enhancements to a standard endoscopy procedure that can help the doctor identify pre-cancerous abnormalities.
- For more information on Barrett’s oesophagus, please use the menu below to navigate through our pages
We recommend that endoscopy procedures should be undertaken by experts. We offer this service. Make an appointment with one of our specialists who will be able to advise you. Please tell our office staff that you want to see an expert in Barrett’s oesophagus. We will ensure you see the right person.
Barrett’s Endoscopic Imaging
On this page we will show you how endoscopic imaging has changed over the last few years. You will also see photographs of chromoendoscopy (using clever colour enhancements to improve the endoscopic images) to assess oesophageal cancer risk.
If you do not want to see photos of the oesophagus, please go to a different page
Types of Endoscopic imaging
Originally, endoscopy used fibre-optics to obtain images. Then video cameras came along and our views of the inside of the body improved dramatically. Over the last few years, the quality of endoscopes has improved exponentially. Just look at these photos and see how much more detail we can now see when we use the best equipment.
White Light Endoscopy
Most endoscopy tests are now done with video systems. Everyone knows that a good camera has 10 mega pixels or more. The more pixels, the better the picture.
The number of pixels in the endoscope picture is tiny compared to a normal camera. Most endoscopes still use about 400,000 pixels (0.4 mega-pixels). But remember: the area being examined is tiny so the resolution is actually higher than a standard camera.
High resolution endoscopy
The latest scopes now have anywhere between 0.8 to 1.2 mega-pixels. This triples the quality of the images and has made an enormous difference. It is like moving from a 3MP to a 10MP camera to take your holiday photos.
Experts can now easily spot most abnormalities which could not be seen even 3 or 4 years ago. Many units do not yet have access to this technology. Each endoscope costs around £30,000 so new equipment is not bought very often!
Even when high resolution scopes are available, it is really important for these endoscopy tests to be done by specialists in Barrett’s oesophagus. Doctors who are not trained in looking for the very subtle early (pre-)cancerous abnormalities will simply not recognize them even though they are visible to experienced, well trained operators.
Chromoendoscopy means using colour to look inside. A number of ‘vital dyes’ have been tried by doctors over the years. These include:
Methylene blue is a blue dye which gets taken up into the cells in the lining of the eosophagus. It makes it easier to see subtle abnormalities. Many studies have been done to see if it improves diagnosis. Sadly, most of them show that it is of ne extra benefit. It is certainly messy and if it gets into the nurse’s or doctor’s clothes, they get ruined! Methylene blue has lost favour because of these weaknesses.
Indigo carmine is a purple dye. Unlike methylene blue, this dye does not get into the cells. Instead, it sits in the tiny crevices and dents between the cells. The purple colour highlights changes in the regular patterns of the cells. This draws the doctor’s eye to areas of abnormality that would not otherwise be seen.
A few studies have been done on the value of indigo carmine in Barrett’s oesophagus. Just like methylene blue, it seems that this dye does not help very much with diagnosis. It does make a mess though!
Acetic acid is also known to most of us as vinegar. This simple substance is perhaps the best of all the ‘dyes’ for detecting abnormalities. Using a simple spraying tool, a small amount of vinegar is sprayed onto the lining of the oesophagus during the endoscopy. It is painless. Within 30 seconds, the colour of the lining changes from salmon red to white. Abnormalities are highlighted. Areas which do not go white often contain (pre-)cancerous abnormalities. These areas are also more likely to bleed a little.
Biopsy samples are taken and sent to the laboratory to confirm the findings. Unlike the older chromoendoscopy dyes, acetic acid does not make a mess. It also disappears within a couple of minutes. It might give the patient a smelly burp or two though!
Virtual Chromoendoscopy Using Digital Image Enhancement
The latest endoscopes have extra imaging modalities built in. These make it easier for the doctor to see abnormalities without needing to use messy dyes.
There are three major image manipulation systems in use.
Narrow Band Imaging on scopes made by Olympus
iScan imaging on scopes made by Pentax
FICE on scopes made by Fujinon
These systems work in different ways, but all aim to do the same thing. That is to detect (pre-) cancerous abnormalities more easily. They manipulate the colour of the images. This really can improve detection. The photographs show how valuable these techniques can be.
Large numbers of patients have been studied using these techniques. These studies have shown that more abnormalities are detected – but not for the reasons you might suspect!
It turns out that better detection is actually due to the longer time doctors spend carefully examining the inner lining of the oesophagus. The way doctors do this, whether with high-resolution, white light or with enhanced imaging appears to be of no importance.
This means that choosing the right doctor to do the test is really important. The key is to find an experienced doctor who knows what to look. Our doctors are amongst the best in the world. We run national and international training courses for other doctors and are at the forefront of research into this new area of medicine
Using advanced imaging techniques is useful, but it does not remove the need for the basic principles which remain:
- Use the latest endoscopy equipment
- Ensure that there are careful biopsy protocols
- The doctor must be completely up to date with latest endoscopic techniques
- We recommend that endoscopic surveillance should be undertaken by experts who understand the best use of chromoendoscopy. Our experts in Barrett’s oesophagus do this type of endoscopy every day of the week.
For more information on Barrett’s oesophagus, please use the menu below to navigate through our pages
If you would like to access our service, please make an appointment with one of our specialists who will be able to advise you. Please tell our office staff that you want to see an expert in Barrett’s oesophagus. We will ensure you see the right person.
Barrett’s Genetics and Oesophageal Cancer Risk
Tumour Suppressor Genes in Barrett’s Oesophagus
When biopsy samples are taken during surveillance endoscopy, the doctor is looking for genetic biomarkers that predict the risk that cancer will develop. The biopsies will often be sent for immunohistochemistry tests. This rather long word means that the samples are stained with special dyes, which pick up important features in the cells. These special dyes pick up more than the standard dyes which are used routinely for all samples.
Barrett’s Genetics and Oesophageal Cancer Risk
LEGEND: Standard staining of a biopsy sample using haematoxylin and eosin (H&E) from a patient with Barrett’s oesophagus
Barrett’s Genetics and Oesophageal Cancer Risk
LEGEND: Immunohistochemistryfor P53, showing increased expression of this biomarker in a patient. This waspublished by one of our research collaborators Murray L et al. Gut 2006 55(10): 1390–1397
LEGEND: Analysis of the cell nuclei from individual cells detects changes in the number of chromosomes. Normal cells are diploid and abnormal cells are aneuploid.
In Barrett’s oesophagus, there is a series of immunohistochemical stains for genetic changes in cells which may be helpful in determining future cancer risk. These include
Tumour suppressor genes such as
Cell cycle regulation markers such as
Other biomarkers of risk
There are many other immunohistochemical stains which may be useful in other diseases but are not useful in Barrett’s oesophagus.
What is the value of immunohistochemistry?
The special dyes and imaging techniques allow the pathologist to be more confident as to whether this patient is at high or low risk of progressing to cancer.
Patients with a high expression of p53 in the biopsy samples, have a likelihood of developing oesophageal cancer in the next five years, that is thought to be significantly higher than in people who do not have this high expression.
Cyclin A expression
We and colleagues in Cambridge showed that finding this particular biomarker in biopsy samples is also a sign that the patient is at higher risk of developing cancer in the next 5 years.
DNA content (aneuploidy) is an important risk factor for cancer
In a landmark series of studies, the Hutchinson Research Labs in Seattle, USA, led by Professor Peter Reid, showed that changes in the amount of DNA in cells, called aneuploidy, was an independent risk factor for developing oesophageal adenocarcinoma (cancer).
Professor Reid followed up almost 250 people with Barrett’s oesophagus who did not have high-grade dysplasia for many years. He used a highly specialised test called flow cytometry. He demonstrated that people who had aneuploidy – altered DNA content – in biopsy samples, had a 28% chance of developing cancer within 5 years. If they did not have this change, their risk was almost zero.
The problem with Professor Reid’s work was that it is not possible for a routine laboratory to do the special ‘flow cytometry’ tests needed to detect the DNA abnormalities.
In our laboratory at UCL, we developed a different way of assessing this DNA content. It is called image cytometry. This technique allows us to assess DNA content more easily from Barrett’s oesophagus biopsy samples. We have shown that our approach works as well as Professor Reid’s.
We believe that we can much more reliably determine if patients are at high or low risk of developing cancer by combining standard analysis of biopsies with DNA content analysis and assessment of other biomarkers.
Combining Biomarkers to Assess Risk
We worked together with colleagues in Cambridge and Belfast to assess almost 500 patients with Barrett’s oesophagus for biomarkers of cancer risk.
Some of these patients developed cancer. Most did not. We worked out which biomarkers could be used together as a panel to determine that risk.
We published some of this work in the prestigious Gastroenterology journal – the top journal in the world in this area in 2013.
Genetics and Familial Risk
It is known that some families are more at risk of developing oesophageal cancer on the background of Barrett’s oesophagus. Currently, very little is known about what predisposes some people to higher risks than others. A big study has shown that there is a gene which is more common in these people. It is not common enough, however, to explain the problem. This is an area which may develop over the next few years.
Immunohistochemistry and other techniques can be used to detect tumour suppressor genes and other biomarkers, which predict the risk that Barrett’s Oesophagus will turn cancerous. For most people, this will never happen. But for the few in whom it will, early detection will allow them to receive curative treatment. We do not yet know enough about familial risk to be able to predict which family members should undergo specialist treatment.
If you would like immunohistochemical assessment of your tumour suppressor genes and other biomarkers of risk, make an appointment with one of our specialists. Please tell our office staff that you want to see an expert in Barrett’s oesophagus
Ablation Treatment in London
HALO Radiofrequency Ablation (RFA), also known as HALO BARRX treatment.
HALO Radiofrequency ablation treatment is a new minimally invasive treatment for Barrett’s oesophagus. It has been developed in the last 10 years and was originally developed by a company called BARRX (hence the name). It can be used to treat Barrett’s oesophagus with dysplasia. It can also be used for Barrett’s oesophagus without dysplasia
When you should consider having Radiofrequency Ablation Treatment (RFA),
According to the UK National Institute for Health and Clinical Excellence (NICE), RFA should be offered to all patients with high grade dysplasia as a routine treatment. For patients with low grade dysplasia or non-dysplastic Barrett’s oesophagus, the evidence to support its use is much less clear. In these situations, the treatment should only be done within strict limits (read the NICE guidance).
For patients with high grade dysplasia, this treatment should only be carried out by experts in centres where large numbers of patients are treated. (see the NICE guidance). All our Barrett’s experts work in these specialist centres and are suitably experienced.
In 2013, the British Society of Gastroenterology (BSG) produced new guidelines on the management of Barrett’s oesophagus.
These new BSG guidelines
Agree with the NICE guidance on when to use RFA.
Extend the recommendation for RFA to include people with a strong family history of oesophageal cancer, even if they do not have high grade dysplasia themselves.
For the first time anywhere in the world, recommend that RFA as the first line treatment for high grade dysplasia. Surgery (oesophagectomy) should now be reserved for those who fail RFA treatment
Success of HALO Radiofrequency Ablation Treatment
The crucial question is how successful is RFA?
In the original trials, success depended on what abnormality was being assessed:
In people with non-dysplastic Barrett’s, the success at 2.5 year after treatment was over 98% eradication of the entire Barrett’s mucosa
In people with low-grade dysplasia, success was over 90%
In people with high-grade dysplasia was eradicated in 81%
In patients with high-grade dysplasia, the Barrett’s oesophagus was also completely reversed to normal lining in around 75% of people.
Long Term Outcomes of HALO Radiofrequency Ablation Treatment
The UK HALO Registry
In the UK, Professor Lovat set up a national registry in 2007 to assess the long term success of this new treatment. Since 2011, he has been running this together with Dr Haidry). They published their initial findings in the most important international medical journal for Gastroenterology in 2013.
- The registry has now enrolled over 700 patients from around the UK.
- The vast majority of these patients have high grade dysplasia or early cancer arising in Barrett’s oesophagus
- The patients have been treated in over 20 hospitals.
- The UK outcomes are very similar to the original trials.
- About 85% of patients with high grade dysplasia in the UK are cleared of this at 12 months
- The success rate in the carefully chosen patients with early cancer is the same as high grade dysplasia
- About 70% of patients also have their entire Barrett’s oesophagus removed and returned to a normal lining
- The shorter the segment of Barrett’s oesophagus, the more successful the treatment
- Long term follow up suggests that more than 90% of successfully treated patients will remain fine
- In the few who relapse, further RFA treatment appears to be successful. Some of these people may also need EMR
- The likelihood of developing invasive cancer in this group of patients appears to be no more than 2% per year. This seems to be an 80% reduction compared to patients not being treated
Risks of Ablation Treatment
All medical treatments carry risks. The good news about this treatment is that the risks appear to be much lower than any of the alternatives.
- The risk of minor bleeding is around 1%
- The risk of major bleeding needing a blood transfusion is less than 1%
- The risk of developing a stricture, narrowing of the gullet, depends on what is wrong with the patient.
- In those with high grade dyplasia, the risk is around 6%
- In those will less severe abnormalities, the risk is lower
- The risk of making a hole (perforation) in the lining of the gullet is less than 1 in a thousand.
- To our knowledge, no-one has yet died as a direct result of this treatment. More than 20,000 procedures have been done world-wide.
What are the alternatives?
Not everyone is suitable for this treatment. Every case must be considered individually.
- For some people, oesophagectomy (surgical removal of the oesophagus/gullet) is needed
- For some people, chemoradiotherapy might be more suitable
- Occasionally, we would recommend laser treatment
- For some people, no treatment is required. This is very unusual but does happen sometimes.
Please remember that BARRX HALO radiofrequency ablation treatment for dysplasia esophagus should be done by experts. We offer this service at our London clinic. If you would like an appointment,, please tell our office staff that you want to see a Barrett’s oesophagus expert. We will make sure you see the right person.
Radiofrequency Ablation Technique Considerations
Radiofrequency ablation treatment is a new treatment for Barrett’s oesophagus. Read on if you would like to understand the technical steps for this treatment. If you prefer to read about why you might want this treatment.
RFA for Barrett’s oesophagus
The treatment is performed at endoscopy. It takes up to an hour to do and can be done under sedation. It does not require a full general anaesthetic.
There are different types of sedation. The usual drugs used are benzodiazepines such as midazolam together with strong pain killers such as fentanyl. These can be given by the endoscopist. They make the patient very sleepy. Most people will have no recollection of the treatment. Some people will, however, remember what is happening. This is particularly so for people who have had many previous endoscopies.
Other drugs such as propofol behave more like a general anaesthetic and put the patient to sleep. These are usually given by an anaesthetist. Patients wake up very quickly after this medicine is given and usually do not have the after-effects of full anaesthesia. Please discuss the type of sedative you are going to have with your doctor.
Most people will have the treatment done as a day-patient and will go home later the same day. For some people, it is better to stay in hospital overnight. This is decided on a case-by-case basis.
Different Types of RFA Treatment
There are two types of RFA treatment:
- A HALO-360 device is used for this.
- This looks like a balloon with closely spaced rings on it.
- Think of the rings as like the heated rear window of your car.
- When the device is switched on, the rings heat up, just like the heated rear window. The difference is that the rings on the HALO device are heat up much faster and are only active for a couple of seconds.
- The devices used for this include the HALO-90, HALO-90 Ultra and HALO-60 devices
- All these devices look like postage stamps – of slightly different sizes!They are used to touch up any areas which have not been completely treated with a HALO-360 device
Circumferential HALO-360 treatment procedure:
The treatment involves these steps:
- Clean the mucus which normally covers the lining the of the oesophagus. This is done most often with a spray called N-acetyl cysteine (NAC or Parvolex)
- Use a special balloon to measure the diameter of the oesophagus. This varies along its length. It is very important to be sure what the minimum diameter is. This reduces the risk of causing damage during treatment
- It is possible to do this step without having the endoscope inside. We think this is unsafe. So we recommend doing this step under direct vision
- Once the minimum diameter of the oesophagus is known, the correct sized treatment balloon is chosen.
- Once again, under direct endoscopic vision, the Barrett’s is treated. Each 3cm length is treated separately. It takes only 3 seconds to treat a 3cm segment. After treatment, the inner lining mucosa turns white.
- After the first 3cm has been treated, the treatment balloon is moved further inside and the next 3cm is treated. It is perfectly safe to re-treat an area so we do not worry too much if there is a little overlap between treatments.
- Once the whole of the Barrett’s oesophagus has been treated, the mucosa can be easily removed.
- The entire treatment is repeated one more time.
Follow Up after Circumferential HALO Treatment
Once the treatment is completed, the patient goes home. Another treatment is offered 2-3 months later. Usually, the second treatment will be a non-circumferential method. This is because most of the Barrett’s will have already been eradicated. The next treatment is to remove any residual areas.
Non-Circumferential HALO Treatment:
This treatment is usually given after an initial HALO-360 treatment.
Some people start off with a short segment of Barrett’s oesophagus. This measures less than 3cm in length. These people may not need the HALO-360 treatment. They might start off with just a non-circumferential treatment.
Three different non-circumferential devices are available.
HALO 90 Ultra
All of these devices do the same thing. They treat small areas of residual Barrett’s oesophagus. The difference between them is simply the size of the area they can treat in one go.
Non-Circumferential HALO Treatment Procedure:
The treatment is very similar to HALO-360:
- Clean the mucus which normally covers the lining the of the oesophagus. This is done most often with a spray called N-acetyl cysteine (NAC or Parvolex)
- No balloon is needed to measure the diameter of the oesophagus as the treatment will not involve a balloon.
- The treatment device is mounted on the end of the endoscope. Under direct endoscopic vision, the Barrett’s is treated. It takes only 2 seconds to treat a single segment. The area is treated twice. After treatment, the inner lining mucosa which has been treated turns white.
- Once all the areas of residual Barrett’s oesophagus has been treated, the mucosa can be easily removed.
- The entire treatment is repeated two more times. This double treatment was shown in research studies to be more effective than doing just a single treatment
Follow Up after Non-Circumferential HALO Treatment
Once the treatment is completed, the patient goes home. Another treatment may be offered 2-3 months later. Most people need 3 treatments. Some need more and some need less. At the last treatment, it is usual to treat the junction between with oesophagus and stomach again. This is because abnormalities often recur at this area.
Follow Up After Treatment
It is very important to do a follow up endoscopy to check that all abnormalities have been removed. We recommend taking biopsy samples from the entire area of the original Barrett’s oesophagus.
We cannot guarantee long term success. Long term follow up is therefore important. We currently recommend 3 monthly endoscopies for the first year after successful treatment. In the second year, we recommend 6 monthly endoscopies. After that, we recommend yearly endoscopies long term.
Radiofrequency ablation should be done by experts. We offer this service.If you would like an appointment, please phone 020 7183 7965 or email us on firstname.lastname@example.org Please tell our office staff that you want to see a Barrett’s oesophagus expert. We will make sure you see the right person.
Surgery – Oesophagectomy
What is Oesophagectomy
Oesophagectomy means removing the oesophagus, or gullet. This is usually done for patients with established esophageal cancer. We offer this service.
This page is about having the surgery for another reason – pre-cancer or early cancer.
Until recently, oesophagectomy was also routinely recommended for people with the pre-cancerous change, high grade dysplasia (HGD) or early cancer arising as a complication of Barrett’s oesophagus.
The new British Society of Gastroenterology guidelines, published in 2013, have, for the first time, suggested that this is no longer first line treatment. Instead, people should first be offered minimally invasive ablative therapies such as HALO radiofrequency ablation (RFA) first. This treatment has a success rate of over 80% in patients with early cancer or high grade dysplasia.
This means, of course, that up to 20% of patients are not cured with HALO RFA. These people should still be considering surgery.
Is surgery right for you?
No one wants to have an operation, particularly if it is a big one. This type of surgery is major. Most people have to stay in the intensive care unit for a few days after surgery and return home after a couple of weeks. It can take around 9 months to return to full health after the operation, so it is not undertaken lightly.
But, if you have early cancer or high grade dysplasia, which is the stage before cancer, then surgery might be right for you.
Of course, it is worth being sure that minimally invasive therapy is not the best option for you before embarking on an operation. But if you have done this, or this treatment has not worked for you, surgery can offer a good solution.
The crucial questions are
Do you have the right abnormality?
Are you fit enough to withstand surgery?
Are you going to a surgeon who has an excellent safety record?
Until a few years ago, one in 20 people would die as a direct result of this operation. Things have improved dramatically now in specialist centres, and for HGD, the likelihood of dying as a result of the surgery is much much lower now, around 1 in 100.
The questions are whether your surgeon does this procedure regularly and what the complication rates are. Feel free to ask him or her! The mortality rate of oesophagectomy and gastrectomy for surgeons in the UK were published for the first time this year, and will be updated regularly. You may see them at<
It is also important to carefully assess the patient’s fitness. We offer extensive and careful pre-operative tests including ECG, blood tests and CPEX (cardiopulmonary exercise testing) to ensure that you are fit enough to have this type of operation.
What to Expect After Surgery
You will be well looked after. The consultant and other members of the surgical team will see you before and every day after surgery. You may need to stay in the Intensive Care Unit or High Dependency Unit for a few days after the operation to ensure that all your bodily functions return to normal. You will then stay in the ward until you feel strong enough to go home.
The biggest change after surgery is eating patterns. Your stomach will be used to replace the part of the oesophagus that is removed. This means that you will have less stomach available to store food. You will have to learn to eat smaller meals more often. You will also almost certainly lose some weight, which you may not regain. You will feel tired initially, but that will pass with time and your eating will also improve over the first few months.
By the first anniversary of the surgery, you can expect to be eating normally and feeling as good as you did before the operation.
If you would like more details on what happens and what to expect after oesophagectomy for HGD and early oesophageal cancer, please feel free to make an appointment with us on 020 7183 7965 .