Barrett's oesophagus
- First described by Norman Barrett in 1950
- Consists of columnar-lined distal oesophagus
- Due intestinal metaplasia of distal oesophageal mucosa
- Can progress to dysplasia and adenocarcinoma
- Its is an acquired condition due to gastro-oesophageal reflux
- Bile reflux appears to be an important aetiological factor
- 10% of patients with GORD develop Barrett's oesophagus
- Approximately 1% of patients with Barrett's oesophagus per year progress to carcinoma
- Barrett's oesophagus increase the risk of cancer by x30
Clinical features
- Barrett's per se is usually asymptomatic
- Usually recognised as an incidental finding at endoscopy
- Appears as 'velvety' epithelium extending more than 3 cm above gastro-oesophageal junction
- The significance of 'short segment' Barrett's (<3 cm long) is unclear
Picture provided by Victor Liew, St George's
Hospital, Sydney, Australia
Management
- If recognised at endoscopy most patients are started on life-long acid suppression
- Little evidence exists that it causes regression of metaplasia
- Anti-reflux surgery may reduce progression to dysplasia and cancer
- Recent interest has been shown in endoscopic mucosal ablation
- Usually achieved with photosensitisers and laser therapy
- The role of endoscopic surveillance of Barrett's oesophagus is controversial
- Aim of surveillance is to detect dysplasia before progression to carcinoma
- 40% patients with dysplasia have focus of adenocarcinoma
- Oesophagectomy for dysplasia has an 80% 5-year survival
Oesophageal carcinoma
Risk factors
- Squamous cell carcinoma
- Alcohol / tobacco
- Diet high in nitrosamines
- Aflatoxins
- Trace element deficiency - molybdenum
- Vitamin deficiencies - vitamins A & C
- Achalasia
- Coeliac Disease
- Genetic - Tylosis
- High incidence in Transkei, Areas of Northern China and the Caspian littoral region
- Adenocarcinoma
- 15% associated with Barrett's Oesophagus
Clinical features
- Progressive dysphagia
- Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula
- Weight loss
Assessment
Diagnosis confirmed by:
- Endoscopy plus biopsy / cytology
- Barium swallow
Resectability and fitness for surgery assessed by:
- Chest x-ray
- Lung function tests(FEV1 > 1L)
- Liver ultrasound
- Endoscopic ultrasound
- Bronchoscopy
- Laparoscopy
- Thoracic CT
Management
- Adenocarcinomas are not radiosensitive and surgery is mainstay of treatment
- Squamous cell carcinomas can be treated with either surgery or radiotherapy
Radiotherapy
- Pearson in Edinburgh (1977)
- 19% 5 years survival with radiotherapy
- Improved survival compared to surgery
- Similar results not seen in other centres
Surgery
- Only 40% tumours are resectable
- Operative mortality now less than 10%
- Treatment should be in centres who perform operation regularly
- No place for the occasional operator
- Preoperative chemotherapy may be beneficial
Operative approaches
Need 10 cm proximal clearance to avoid submucosal spread.
- Total gastrectomy via thoracoabdominal approach (Adenocarcinoma)
- Subtotal two-stage oesophagectomy (Ivor-Lewis)
- Subtotal three-stage oesophagectomy (McKeown)
- Transhiatal oesophagectomy
Palliative treatment
Aim to relieve obstruction and dysphagia with minimal morbidity
- Oesophageal intubation
- Open surgical intubation (Celestin or Mousseau-Barbin tubes) now obsolete
- Endoscopic or radiological placement now most commonly practiced
- Atkinson tube is the most commonly placed endoscopically
- Requires dilatation with risk of oesophageal perforation
- Recent increased use of self-expanding stents that require no pre-dilatation
- Complications of stents and tubes:
- Oesophageal perforation
- Tube displacement or migration
- Tube blockage due to ingrowth or overgrowth
- Laser therapy
- Produces good palliation in over 60% of cases
- May need to be repeated every 4 to 6 weeks
- Associated with oesophageal perforation in about 5% cases
- External beam radiotherapy
- Brachytherapy
- Diathermy
- Alcohol injection
Bibliography
Basu K K, de Caestecker J S. Surveillance in Barrett's oesophagus. Postgrad Med J
2002; 78: 263-268.
Cowling M G. Stenting in the oesophagus. Hosp Med 2000; 61: 33-66.
Kubba A K, Krasner N. An update in the palliative management of malignant dysphagia. Eur J
Surg Oncol 2000; 26: 116-129.
Medical Research Council Oesophageal Cancer Working Party. Surgical resection with or without
preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 2002;
359: 1727-1733.
Pennathur A, Gibson M K, Jobe B A et al.
Oesophageal carcinoma. Lancet 2013; 381:
400-412
Shaheen N J, Richter J E. Barrett's oesophagus.
Lancet 2009; 373: 850-861
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