Therapeutic endoscopy

Barrett's oesophagus occurs when the epithelium (the outermost layer of the oesophageal wall) is replaced by another type of epithelium containing intestinal-type cells as a result of ongoing damage from gastroesophageal reflux (which is usually acidic), a condition known as intestinal metaplasia.

There are different types or grades of Barrett's oesophagus, according to the biopsy results and microscopic study. The grades can be:

• Intestinal metaplasia without dysplasia
• Intestinal metaplasia with low-grade dysplasia
• Intestinal metaplasia with high-grade dysplasia

Dysplasia refers to the inherent alterations of a tissue or cell, making it more disorganised and similar to a cancerous cell. Although dysplasia increases cancer risk, it is not considered cancer itself but rather a precancerous lesion. Ultimately, high-grade dysplasia may be considered cancer if there are signs of tissue invasion. As there is a risk of developing oesophageal cancer, it is very important to identify patients with this condition, make an accurate diagnosis, and establish the most precise and effective treatment. That is why our patients have access to the Barrett's Oesophagus Unit, made up of specialists offering the most accurate diagnosis and treatment, as well as the most innovative techniques.

What are the risks for a patient with Barrett's oesophagus?

Barrett’s oesophagus increases the risk of developing oesophageal adenocarcinoma (a specific type of cancer). Although all grades of Barrett’s oesophagus increase the patient’s risk compared to the general population, low- and high-grade dysplasia present the greatest risk.

* Data from Sharma P, Falk GW, Weston AP, et al.
Dysplasia and cancer in a large multicentre cohort of patients with Barrett's oesophagus.
Clin Gastroenterol Hepatol 2006; 4:566-572

How is diagnosis performed?

Diagnosis is performed using high-resolution magnification endoscopy (image enhancement), employing additional chromoendoscopy techniques conducted by endoscopists specialised in the early diagnosis of premalignant lesions, with targeted biopsies for analysis.

Diagnóstico esógafo de Barrett

When should Barrett's oesophagus be treated and which technique is indicated in each case?

Barrett's oesophagus should currently only be treated when dysplasia appears and is maintained or confirmed in a follow-up at 3-6 months (depending on the degree of dysplasia), with radiofrequency being the technique of choice if there are no visible lesions. Mucosectomy followed by radiofrequency on the remaining Barrett's oesophagus is the technique of choice if these lesions exist.

Treating Barrett's oesophagus involves controlling acid or gastroesophageal reflux to prevent it from progressing. High-dose treatment with acid production inhibitors is the treatment of choice, with antireflux surgery being considered as an alternative.

técnica diagnóstico esófago barrett

Endoscopic Techniques for the Treatment of Barrett's Oesophagus

• Endoscopic mucosectomy
• Endoscopic mucosal resection involves the endoscopic removal of a section of the mucosa and submucosa (in this case of the oesophagus). It is indicated whenever elevated lesions are observed in Barrett's oesophagus during diagnostic endoscopy.
• This diagnostic test is conducted on an outpatient basis, with patients remaining under observation in the day hospital for a few hours.

• Radiofrequency with HALO system
• The HALO radiofrequency ablation system safely and uniformly ablates the oesophageal mucosa to a depth of approximately 1 mm. Ablation is a technique in which tissue is heated until it is no longer viable or alive. HALO technology is a very specific type of ablation where heat energy is applied precisely and in a controlled manner. Clinical trials have demonstrated that Barrett's tissue can be completely eliminated with HALO ablation technology in 98.4% of patients.
• Endoscopic follow-up is required, and treatment generally needs to be repeated in one or two sessions.

How should Barrett's oesophagus be monitored?

An initial endoscopy with biopsies should be performed following the Seattle protocol. An endoscopic checkup is recommended after one year if there is no dysplasia but Barrett’s oesophagus is present, simultaneously increasing the dose of the gastric protector or its derivatives and ensuring complete inhibition of acid reflux through pH monitoring.

An endoscopic check is performed every 2-3 years if the second endoscopy still shows no dysplasia and the acid is controlled.

Endoscopic treatment is indicated whenever dysplasia is confirmed in a second checkup.

Gallstones are small stones that form inside the gallbladder, ranging in size from microscopic crystals to larger stones comparable to a golf ball. They form due to a combination of various factors and can eventually lead to choledocholithiasis (partial or total obstruction of the bile duct caused by stones/calculi).

Endoscopy is valuable for both diagnosing and preventing disease through endoscopic ultrasound, which uses a specialised endoscope to produce images of the bile duct from within the stomach and duodenum, allowing clear visualisation of the bile duct and detection of choledocholithiasis without interference.

Choledocholithiasis requires relatively urgent treatment, depending on the clinical presentation and progression; however, most stones can be removed endoscopically using the ERCP technique, which combines endoscopy with radiology, thus avoiding the need for surgery.

Fibroscan:

Among the different techniques we use to treat biliary diseases, Fibroscan (or transient elastography) stands out as a cutting-edge method that enables painless, non-invasive diagnosis of fibrosis. This technique evaluates 100 times more area than a biopsy.

These results help predict potential complications, as well as monitor and assess damage caused by liver diseases, providing valuable information for making decisions about treatment, follow-up, and both the short- and long-term prognosis of the condition.

The same FibroScan device may incorporate the CAP (controlled attenuation parameter), which is the only non-invasive test to quantify hepatic steatosis (fatty liver). Today it is one of the most common causes of liver transplant.

With CAP, it is possible to detect steatosis from as little as 5%, unlike ultrasound, which only detects it from 30% onwards.

Endoscopic ultrasound or endoscopic ultrasonography integrates ultrasound and endoscopic studies into a single examination.

Endoscopic ultrasound allows direct visualisation of the oesophagus, stomach, duodenum, rectum, sigmoid colon, and surrounding structures (bile duct, pancreatic region, pelvic cavity, thoracic and upper abdominal arteries and veins, kidneys, and adrenal glands, etc.).

The echoendoscope is inserted through the mouth or anus and features a built-in video camera that transmits live images of the digestive tract walls to a monitor. Echo-endoscopy is not painful; however, it requires intravenous sedation of varying intensity, as it is technically a complex and lengthy procedure.

Endoscopic ultrasound usually consists of two phases: an exploratory phase, and a second interventional phase.

The second phase depends on the findings during the exploratory phase. For example, if an anomaly is confirmed, it may be necessary to take samples for diagnosis (diagnostic endoscopic ultrasound). The procedure can also be therapeutic if a cyst or abscess drainage is performed, or if it is used to access the bile or pancreatic ducts.

Endoscopic ultrasound is an invasive procedure that exposes the patient to risks. Fortunately, the risks are statistically low; however, it is important to evaluate the need for the test with the medical team on a case-by-case basis.