Box Butte General Hospital (BBGH) will soon be providing a state-of-the-art treatment for Barrett’s Esophagus, a precursor to cancer of the esophagus, through its Greater Nebraska Medical and Surgical Services (GNMSS) General and Trauma Surgery clinic. Patients requiring this new procedure currently have to travel as far away as Lincoln or Denver for treatment.
General and Fellowship Trained Trauma Surgeon Paul Willette, MD, explained why providing this new procedure is so important to Greater Nebraska residents. “We want to be on the preventive side of treatment, because once you get esophagus cancer the prognosis is poor,” he said. “Surgery, radiation and chemotherapy haven’t really changed the outcomes for esophagus cancer, so if we can prevent this by being proactive rather than reactive, that’s where we want to be. This new procedure provides the means to do that.”
To comprehend why this procedure is so important and ground breaking, Dr. Willette said residents need to understand the whole picture of how Barrett’s Esophagus occurs. “Gastroesophageal Reflux Disease (GERD), commonly called gastric reflux, and Barrett’s Esophagus are intrinsically related,” he said.
GERD is the third most prevalent disease in the United States, with half of U.S. adults experiencing symptoms almost monthly and 20 percent weekly. “The epidemic of GERD is due to our “super-size” culture and unhealthy eating habits, resulting in more than half of the U.S. population being overweight or obese,” Dr. Willette said.
Barrett’s Esophagus, which is caused by gastric reflux, is a precursor of adenocarcinoma of the esophagus (cancer of the esophagus). “Cancer of the esophagus is the most rapidly increasing form of cancer in the U.S.,” Dr. Willette reported. “It is rising faster than breast cancer, prostate cancer or melanoma (see Graphic A). So if we can effectively treat Barrett’s before it possibly turns into esophagus cancer, then we’re being preventative rather the reactive; similar to when we remove polyps discovered during colonoscopies to prevent colon cancer, or removing breast masses to prevent breast cancer and moles to prevent malignant melanoma. To do that, a very effective and very safe treatment for Barrett’s has been fully developed and tested by a team of researchers at Mayo Clinic in Rochester, MN. The proven technology, ablation using the HALO system, went ‘live’ this past year. They’ve really made this technology incredibly safe. I’ve already trained in its use, and am excited that the procedure will be available very soon at BBGH.”
The surgeon gave a comprehensive review of how the gastric reflux occurs, and the complications it causes to the esophagitis.
Dr. Willette said causes of gastric reflux include people having trouble with their lower esophageal sphincter (LES), as well as diet triggers such as chocolate and fatty foods, smoking, and some medications (see Graphic B). “As far as the LES, it helps maintain a pressure barrier that keeps the contents of the stomach from moving up into the esophagus,” he said. “If the muscles weaken and lose tone, the LES is unable to close completely, which allows gastric secretions to ‘reflux’ into the esophagus.” Simple physics explains why. “It’s a matter of fluid in an area with more pressure (the stomach) flowing to an area with less pressure (the esophagus),” he explained.
When gastric reflux occurs, it damages the esophagus. Complications include: Erosive esophagitis; Stricture formation; Ulceration; Barrett’s Esophagus; and the deadly complication of Esophageal Cancer.
“What we want to focus on is Barrett’s Esophagus,” Dr. Willette said, “and the new procedure we will be offering at BBGH that safely and effectively eliminates Barrett’s tissue from the esophagus.”
As stated before, Barrett’s is a pre-cancerous condition of the lining of the esophagus in which the esophageal lining changes, becoming similar in color to the tissue that line the intestine.The change from one type of cell to another may generally be a part of normal maturation process or caused by some sort of abnormal stimulus, in this case gastric reflux. “Here’s what happens when Barrett’s occurs,” he explained. “Gastric reflux can cause the cells lining the esophagus to transform. When a normal cell transforms to become a different normal cell, it is called metaplasia. But when one cell becomes an abnormal cell, it’s called dysplasia. Metaplasia is okay, but dysplasia isn’t. Dysplasia cells can go on to become esophagus cancer. That’s why in the past when Barrett’s was found in a patient the most common treatment was surveillance. We monitor it constantly, conducting periodic Endoscopies (EGDs) and taking biopsies to make sure the cells don’t become dysplasia in characteristic. Now, with this new treatment, we can go beyond monitoring and all the uncertainty that causes a patient to the preventative removal of Barrett’s tissue in a safe and effective manner.”
Barrett’s Esophagus is easily diagnosed using the non-surgical EGD procedure. The surgeon, with the patient conscious but sedated, inserts a small flexible tube with a light at the end (the endoscope) through the mouth and into the esophagus. This tube has a camera that allows the physician to look at the lining of the esophagus. “Barrett’s Esophagus tissue has a very prominent salmon color, compared to the flesh coloration of normal esophagus tissue (see Graphic D). It’s easily discernible,” Dr. Willette explained.
The newly developed HALO treatment uses ablation to remove Barrett Esophagus tissue. Ablation is the use of radiofrequency energy to heat unwanted or diseased cells to the point of cell death. “This technology has been tested and is very safe,” Dr. Willette said. The HALO ablation technology delivers radiofrequency in a unique way, optimizing the removal of unwanted diseased tissue yet minimizing injury to normal esophagus tissue. Larger areas of Barrett’s tissue are treated with a balloon-based HALO ablation catheter, while smaller focal areas of Barrett’s tissue are treated with an endoscope-mounted HALO catheter. “The first treatment with the balloon catheter will usually remove around 95 percent of Barrett’s tissue,” Dr. Willette explained. “The final 5 percent is removed during a second procedure a couple of months later using the endoscope-mounted catheter. And the reason this is so safe is the HALO computer system limits the amount of energy produced. After a certain amount of energy is used to treat the Barrett’s tissue, it shuts itself off. As you can see, the results are amazing (see Diagram C).”
Dr. Willette believes the steep rise in esophagus cancer can be attributed to improved medications (both over the counter and prescription) available to eliminate acid in reflux occurrences. “But it doesn’t matter if a person takes medication that relieves the pain associated with gastric reflux,” he said. “When people who have gastric reflux self-medicate to get rid of the acid and thus the pain, yes, the acid is reduced and the pain goes away. But you haven’t neutralized the risk of developing Barrett’s or other complications of the esophagus because the weak LES is still allowing other stomach fluid contents, such as pepsin (a powerful enzyme in gastric juice that digests proteins such as meat, eggs, seeds and dairy products) and bile salts to enter the esophagus, causing more damage over time. If no pain, then you have the false security of not needing an EGD done. If you don’t have an EGD done, then potential complications in the esophagus aren’t found until they have progressed further than need be.”
Dr. Willette plans a two-prong approach on the post-op procedures after Barrett’s tissue is successfully removed. “First, the patient’s progress will be monitored via return visits for EGDs, the number of which is determined by how severe a case of Barrett’s the patient had. The second approach is to take care of the original gastric reflux that caused it in the first place, if need be. Think of the LES as a gate. If it’s tight, it closes off the damaging fluids of the stomach from the esophagus. On the other hand if it’s loose and the gate doesn’t work, then we have to create a situation anatomically that tightens that gate so that we mitigate any further damage to the esophagus. By repairing the gate, we greatly reduce the chance of Barrett’s, or other complications, coming back.”
The Barrett’s Esophagus procedure using the HALO Ablation system will become available at BBGH the end of November.
BBGH is a non-profit, county owned 25-bed Critical Access Hospital. The mission of BBGH is to lead and innovate in healthcare delivery and community wellness.