Barrett's Oesophagus - Ablative Therapy

Main Category: GastroIntestinal / Gastroenterology
Article Date: 16 Aug 2010 - 5:00 PDT

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NICE has published its clinical guideline on the use of ablative therapies for the treatment of Barrett's oesophagus. Ablative therapies destroy the abnormal cells within the oesophagus (sometimes known as the gullet, it is the muscular tube through which food passes from the throat to the stomach) caused by this condition, without the need to remove an entire section of oesophagus. This is the first time national guidelines have recommended the use of these therapies to treat this condition.

Barrett's oesophagus (also known as Barrett's)[1] is a condition which affects the lower oesophagus and develops as a consequence of long-term, chronic gastro-oesophageal reflux disease (GORD)[2]. The cells that line the affected area of the oesophagus become inflamed and if this happens over many years, these cells may start to change, becoming more like the cells that line the intestine. In some patients, these changes can lead to oesophageal cancer.

Barrett's oesophagus does not present any symptoms in itself, but can be associated with the following:

- frequent and longstanding heartburn
- difficulty swallowing (dysphagia)
- vomiting blood
- pain under the breastbone where the oesophagus meets the stomach.

Surgical removal of all or part of the oesophagus (oesophagectomy) is the current standard NHS treatment for Barrett's oesophagus, but less invasive techniques such as endoscopic resection (ER)[3] and ablative treatments have now been developed.

The guideline recommends that clinicians consider offering patients endoscopic resection (ER) of high-grade dysplasia[4] and intramucosal cancer (including T1a [5]) as an alternative to removal of the affected part of the oesophagus (oesophagectomy), taking into consideration patient preference and general health. ER should also be considered alone, to treat localised lesions.

This guideline covers the use of ablative therapies (argon plasma coagulation [APC], laser ablation, multipolar electrocoagulation [MPEC], radiofrequency ablation [RFA] and photodynamic therapy [PDT]), and endoscopic resection (ER), for treating Barrett's oesophagus with high-grade dysplasia or with intramucosal cancer (including T1a) in adults (18 years and older) in secondary care.

The recommendations state that an additional ablative therapy (RFA, APC, or PDT) could be used after ER to completely remove dysplasia, and RFA or PDT ablation alone could be considered for flat high-grade dysplasia. APC, laser or MPEC should not be used alone or in combination with each other unless as part of a clinical trial.

Dr Fergus Macbeth, Centre for Clinical Practice Director at NICE, said: "Barrett's oesophagus, apart from being a distressing condition in itself, can sometimes lead to cancer of the oesophagus. Therefore, it's important that the NHS is treating it in the most clinically and cost effective way. This will be the first national guideline to cover the use of ablative therapies, and will ensure that the widest range of options is considered for patients suffering with this serious condition. The recommendations may lead to less costly treatments, and fewer recalls and complications after treatment. Additionally, because more patients are eligible or fit enough to undergo endoscopic procedures than surgery, future savings for the NHS might come from cases of oesophageal cancer avoided."

Dr Damien Longson, Guideline Development Group Chair, said: "Barrett's oesophagus currently affects about 1% of the population, so it's crucial that the best treatments are available to treat it. These ablation therapies can destroy the abnormal cells without the need to remove the entire oesophagus, and represent a real step forward in clinically and cost effective treatment for this condition."

Mimi McCord, Patient / Carer Representative, Guideline Development Group, said:

"I am so pleased NICE is publishing these guidelines. Barrett's oesophagus can be an extremely upsetting and worrying condition, and these therapies show us what really works in the fight against it."

When NICE publishes clinical guidelines, local health organisations should review their management of clinical conditions against the NICE guidelines. This review should consider all resources required to implement the guidelines. NICE guidelines however, are not intended to replace the knowledge and skills of individual health professionals who treat patients; it is still up to them to make decisions about a particular patient.

Notes

About the guidance

1. See this clincal guideline

[1] Another name sometimes used by doctors for Barrett's oesophagus is columnar-lined oesophagus (CLO).

[2] Chronic gastro-oesophageal reflux disease is defined as chronic symptoms or mucosal damage in the oesophagus, produced by the liquid content of the stomach when it regurgitates into the oesophagus. This liquid can inflame and damage the lining, and usually contains acid and pepsin that are produced by the stomach. It may also contain bile that has backed-up into the stomach from the duodenum.

[3] ER is a procedure whereby specialised endoscopic devices are used to remove abnormal areas in the lining of the oesophagus.

[4] Abnormal cell growths that can sometimes lead to oesophageal cancer.

[5] T1a is a classification of cancer that shows less than 5% of cancerous cells in the tissue sample.

Source:
NICE

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