Physicians can help stem the rising incidence of gastroesophageal cancers by aggressively treating patients with gastroesophageal reflux (GERD) and Barrett's esophagus.
Barrett's esophagus: aggressive treatment helps prevent progression to cancer
Large hiatal hernias can develop in patients with long-standing gastroesophageal reflux.
Recent research suggests that the obesity epidemic may be partly to blame for these increasing cancer rates. Obese patients are more likely to develop GERD, a condition that occurs when the lower esophageal sphincter at the end of the esophagus fails to close properly. Harsh stomach acids then leak back into the esophagus and can irritate the esophageal lining. In some patients, GERD can cause the normal cells of the esophageal lining to change into abnormal, precancerous cells. About 1 percent of patients with this condition, called Barrett’s esophagus, develop esophageal cancer.
GERD and Barrett’s esophagus are so closely linked that it is vital for patients to receive coordinated care from physicians who can address both conditions. However, studies showing conflicting results over the effectiveness of antireflux surgery have made it difficult for physicians to make the right choices for their patients.
In 2008, Massachusetts General Hospital researchers published results of a landmark 10-year study that helped resolve this controversy. A team of researchers surveyed 200 patients who underwent primary laparoscopic fundoplication procedures from 1997 through 2006 to reestablish the competence of the lower esophageal sphincter and repair any coexisting hiatal hernias.
Patients who participated in the study responded to a survey months after their procedure. The median follow-up time was 60 months. Survey results indicated that patients achieved excellent results with near-normal quality-of-life scores and significant and lasting relief. Most patients discontinued acid-suppressive medications. More than 70 percent were very satisfied with their long-term outcome. In addition, their reoperation rate was very low - less than 1.2 percent.
This study on long-term outcomes, which was published in the May 2008 issue of Archives of Surgery, represents the largest series of laparoscopic fundoplication procedures reported in New England. All patients surveyed for the study had their procedures at Massachusetts General Hospital.
New Program Offers Unparalleled Care
In 2008, the hospital’s Digestive Healthcare Center—a leading referral center for GERD and Barrett’s esophagus—became one of the first in the country to develop a dedicated Barrett’s esophagus program that offers expert diagnostic testing and multiple medical and surgical treatment modalities in one centralized location.
A multidisciplinary team of gastroenterologists, surgeons, pathologists, radiologists, nurse coordinators, and diagnostic technicians work exclusively to provide individualized services to patients with Barrett’s esophagus and/or GERD and coordinate patients’ care with their referring physicians. The program’s fellowshiptrained physicians are recognized nationally and internationally for their medical and surgical expertise.
Massachusetts General Hospital, for example, was the first facility in New England to perform laparoscopic antireflux surgery in 1991.
Endoscopic view of an irregular “Z-line” due to Barrett’s esophagus in this patient
Specialists in the Mass General Barrett’s Esophagus Treatment Center offer a complete range of therapies for GERD. Conservative medical therapies, including proton pump inhibitors (PPIs) and other prescription and over-the-counter drugs, work for many patients with reflux. Surgery may be warranted in patients who:
The program’s surgeons have a proven record of accomplishment in performing successful primary laparoscopic fundoplication procedures that give most patients the relief they seek. They are also skilled in managing patients who have had previous unsuccessful antireflux surgeries.
Endoscopic mucosal resection (EMR) may be the treatment of choice for patients who have nodular Barrett’s esophagus or suspicious tissue that may be malignant.
Targeting Barrett's Esophagus
It is important to evaluate patients with GERD for Barrett’s esophagus and determine the presence and/or level of dysplasia. Treatment strategies vary for each patient depending on the extent of the patient’s disease, age, and overall health. Surveillance is appropriate for some patients with mild disease or who are an advanced age.
The treatment model for Barrett’s esophagus with high-grade dysplasia or early esophageal cancers has shifted radically over the past five years. Esophagectomies or surgical removal of the esophagus is no longer the first line of treatment for these patients.
Dysplasia can typically be managed with ablation procedures, including radiofrequency ablation, cryoablation, and photodynamic therapy. These procedures, which ablate the abnormal mucosa, are safe and reliable. They have both high success rates and low complication rates. Patients may also need fundoplication procedures to protect the new esophageal lining from stomach acids. With good control of acid reflux, Barrett’s esophagus generally does not return.
Endoscopic mucosal resection (EMR) may be the treatment of choice for patients who have nodular Barrett’s esophagus or suspicious tissue that may be malignant. This technique allows surgeons to remove small areas about the size of a dime and examine the tissue immediately. Studies show that using EMR to remove cancers and ablation to treat Barrett’s esophagus is an effective and less invasive option for treating patients with very early and superficial esophageal cancers.
Esophagectomy is now reserved for people with invasive esophageal cancers that cannot be eradicated with EMR. Massachusetts General Hospital is one of the few facilities in Boston offering minimally invasive esophagectomies. Virtually all patients who need esophagectomies, including those who have been treated for Barrett’s esophagus and/or GERD, are candidates for minimally invasive procedures.
Surgeons performing this technically demanding surgery use two scopes, one in the chest and another in the abdomen, and complete the procedure without separating the ribs. Patients who have minimally invasive esophagectomies tend to have less pain, fewer complications, and faster recoveries.
Research shows that oncological results of open and minimally invasive esophagectomies are equivalent. Massachusetts General Hospital is collecting data on all patients who have esophagectomies to compare the results and costs of conventional and minimally invasive surgery.
Please visit the Massachusetts General Digestive Healthcare Center’s website for information on a one-credit CME session on the topic of Barrett’s esophagus: massgeneral.org/digestive
|David W. Rattner, MD
|Christopher R. Morse, MD
Massachusetts General Hospital Digestive Healthcare Center
The Digestive Healthcare Center is organized into six disease areas dedicated to the diagnosis and management of digestive health issues. For more information about these services, visit massgeneral.org/digestive. The Massachusetts General Hospital Digestive Healthcare Center is a collaborative practice of gastroenterologists, endoscopists, surgeons, radiologists, pathologists, hepatologists, oncologists, and radiation oncologists dedicated to the prevention, diagnosis, treatment, and management of digestive diseases.
The Digestive Healthcare Center offers a full range of medical and surgical treatments for digestive diseases, including conditions of the esophagus, stomach, small and large intestine, liver, gallbladder, pancreas, and colon.
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