What is GERD?

Barrett's Esophagus

This is a specific form of gastric type mucosa in the lower portion of the gullet. Barrett's esophagus forms as a consequence of reflux. Approximately 20% of those with GERD symptoms (heartburn etc.) have Barrett's esophagus.

Barrett's esophagus may progress towards esophageal cancer (0.5% per year), i.e. 1 out of 10 persons with Barrett's will develop cancer in 20 years. Since it is currently not known, who of those with Barrett's will develop cancer, those with Barrett's esophagus are recommended to undergo surveillance endoscopy every 3-5 years. In case of progression towards cancer specific endoscopic and/or surgical therapies are recommended and should be discussed with your physician (endoscopist, internist, surgeon).

Conceptually, treatment options for Barrett's esophagus include medical (PPI), ablative (endoscopic removal of the abnormal mucosa) and surgical (antireflux procedure) therapy and should be discussed with your physician.

NEW: Endoscopic removal of Barrett's mucosa by radiofrequency ablation

Barrett's esophagus results from gastroesophageal reflux and describes a condition where the normal mucosa of the gullet is replaced by a premalignant mucosa of gastric type. Radiofrequency ablation (RFA) of the Barrett's mucosa is now available for clinical routine and offers the fascinating opportunity to remove the Barrett's mucosa without affecting esophageal function. Conceptually RFA removes the 'bad' mucosa, which is replaced by the 'good' normal mucosa of the gullet. After the treatment continuous medical therapy with high dose proton pump inhibitor (PPI) or an antireflux surgery is necessary to inhibit reformation of the ?bad? Barrett?s mucosa. RFA is highly effective to remove Barrett's esophagus (95%), dysplasia (80%-90%) and early cancer (70%-80%). Thus the novel fascinating technology will profoundly improve the management of those with Barrett's dysplasia and early cancer. In addition it may replace the surgical resection of the esophagus for dysplasia and early cancer.

RFA is a day care, endoscopic procedure conducted under sedoanalgesia. RFA works by introduction of a catheter-mounted non-inflated balloon into the gullet. Under endoscopic vision, the balloon is positioned at the level of the 'bad' mucosa. Then the balloon is inflated with air so that its surface, which is covered with a string for energy delivery, stays in direct contact with the mucosa. During a short pulse of radiofrequency energy the 'bad' mucosa is destroyed. Following delivery of the energy the balloon is removed and the destroyed mucosa is scrapped off with a special cap mounted on the tip of the endoscope. After that the procedure is repeated. Thus, one treatment includes 2 cycles of energy delivery towards the 'bad' mucosa and lasts approximately 20-30 min.

Radiofrequency ablation for the removal of Barrett's mucosa

Figure 1: Radiofrequency ablation for the removal of Barrett's mucosa

For the removal of Barrett's mucosa involving the whole circumference of the gullet we use the so called 360° ablation balloon. Barrett's mucosa including parts of the circumference we use the 90° energy applicator, which looks like a 'spoon'.

The great thing here is that RFA removes the 'bad' mucosa without affecting the function of the esophagus. Within 4-6 weeks after the treatment the area of the eradicated Barrett's mucosa is replaced by a normal mucosa of the esophagus. However, it is important to be kept on high dose therapy with a proton pump inhibitor (PPI), otherwise Barrett's may relapse.

Following the treatment you may have heartburn and difficulties to swallow for 2-5 days, which is antagonized by respective analgetic medication.

Follow up endoscopy is conducted 4-6 weeks after the ablation. If remaining Barrett's mucosa is detected a second treatment is done. Otherwise follow up endoscopies are recommended in 6 and 12 months.

Since reflux control is required to prevent reformation of the Barrett's mucosa, antireflux surgery may be considered after the ablation of the Barrett's mucosa. Arguments in favor of an antireflux procedure include PPI sensitive Reflux disease, young age, dislike to take life long PPI and presence of non acid reflux under PPI treatment. Prior to decision making patients should undergo esophageal function test (manometry, pH monitoring).