Episode 148 - Barrett’s Oesophagus, Endoscopic Mucosal Resection and Radio Frequency Ablation with Professor Finlay Macrae

Barrett’s oesophagus is a common condition, named after the Australian born thoracic surgeon Norman Barrett who practised in England and laid the foundation descriptions of this condition but incorrectly concluded the abnormal columnar tissue lining was embryonic in origin due to the presence of a congenitally shortened oesophagus leading to a tubular portion of stomach being trapped in the chest.  We now recognise that between 5-10 % of patients with chronic reflux disease develop columnar metaplasia as a response to repeated oesophageal acid exposure.

Long segment disease extends for more than 3 cm, short segment less than 3 cm and metaplasia at the OG junction (less than 1 cm in length) is not considered to be pathological. 

Its presence informs us that our patient has GORD and alerts to the possibility of dysplastic change and malignant transformation. Although the latter is relatively unlikely in any individual the risk is real. Estimates quote 0.33 to 0.5 % risk per year, that is 1: 200 per year which is 30-125 times the average population risk. Malignant risk increases with longer lengths of Barrett’s, Caucasian males and smokers but is probably not influenced by alcohol history.

In the absence of invasive malignancy, nodular areas are removed by a mucosal stripping technique described as endoscopic mucosal resection (EMR) and remaining lengths of Barrett’s mucosa may be removed using radio frequency ablation (RFA). This ablative technique involves the use of radiofrequency energy delivered with balloon-based catheters that heats the oesophageal mucosa and destroys non dysplastic and dysplastic tissue.

Randomised control trials have demonstrated superiority over sham ablation in limiting dysplasia and metaplasia at one year. The technique is associated with a lower stricture rate and decreased post procedure morbidity than other techniques sometimes utilised in this situation such as photodynamic therapy or cryotherapy.

I was keen to have a conversation with Professor Finlay Macrae on this important subject exploring the topic of Barrett’s in more length as well as the techniques of EMR and RFA. Professor Macrae is a gastroenterology mentor, head of colorectal medicine and genetics at the Royal Melbourne Hospital and has public and private practices focusing on the management of Barrett’s oesophagus, inflammatory bowel disease and familial bowel cancer. He trained both in Melbourne and at St Marks Hospital in London. In 2016 he was awarded the Order of Australia for his work in genetics and genomics.

Professor Macrae has been delivering advanced therapeutic solutions for patients with complex Barrett’s disease for over 30 years and was therefore, an obvious choice of expert guest to discuss this topic today, it was a great privilege to have this conversation with him.

References:

Professorfinlaymacrae.com

Spechler S.et al. Barrett’s Esophagus. N ENG J Med 2014; 371:836-45

Whiteman et al. Journal of Gastroenterology and Hepatology 30 (2015) 804-820

Cancer Council Australia Barrett’s Oesophagus Guidelines Working Party. Clinical Practice Guidelines for the Diagnosis and Management of Barrett’s Oesophagus and Early Oesophageal Adenocarcinoma. Feb 12.2015