Primary Motility  Disorders of the  Esophagus
 The Esophageal
 Mucosa
 The
 Esophagogastric  Junction
 Barrett's
 Esophagus

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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Screening and surveillance
 

What is the average length of follow-up necessary to document regression of Barrett's esophagus?

I.G. Martin (Auckland)

The issues surrounding the regression of Barrett's esophagus are all controversial. This section deals with one aspect of this controversy, the time scales involved. Potentially, regression can occur in two settings, firstly following effective medical or surgical treatment and secondly after ablative therapy aimed at removing the metaplastic mucosa allowing squamous regeneration in a reflux free environment. The question itself has two components. Firstly, how rapidly does regression, if it should occur, happen after antireflux therapy and secondly following ablation therapy, how long do you have to follow-up patients for, to confidently state the Barrett's has been successfully removed.

Time course of changes in the extent of Barrett's esophagus following medical therapy

It has to be stated that complete regression of Barrett's esophagus is very rarely seen after even the most effective treatment with proton pump inhibitor (PPI) treatment [1]. Very few studies have looked at the time course of changes in the extent of Barrett's esophagus. In what is probably the most detailed study in this area, Peters et al. demonstrated a small but significant reductions both in the area and length of Barrett's esophagus in patients on PPI therapy. There were slow and with the passage of time decreases in the total area of Barrett's mucosa, with a mean reduction of some 8% at 24 months of follow-up. In this study no patient showed complete regression. The extent of the Barrett's esophagus seemed to decrease consistently throughout the 24 months of the study and it may be that a longer period of follow-up would have shown greater decreases in the extent of the Barrett's esophagus.

However, the endoscopic finding that accounts for most of the reductions in area seen are squamous islands. If these islands are biopsied, then in around 40% of cases Barrett's mucosa will be found [2]. This "buried" glandular mucosa is susceptible to neoplastic change and therefore this finding calls into question the whole concept that regression can be quantified by macroscopic findings of squamous re-epithelialization.

It is currently impossible to give any further details regarding the time course of changes in the extent of Barrett's esophagus.

Time course of changes in the extent of Barrett's esophagus following surgical therapy

There is limited evidence that surgery can induce apparent regression in a number of patients with Barrett's esophagus. A small number of patients will have endoscopic complete regression following surgery. However the data is patchy and few if any studies have adequately looked at the issue of growth of squamous mucosa over glandular Barrett's epithelia. Published studies, recently reviewed by both Haag [1] and DeMeester [3], are very heterogenous in both quality and results. The studies followed patients for between 3 months and 12 years. On the basis of these studies it is not possible to comment on the time course of any regression after surgical treatment.

What of ablation treatments?

Ablation therapies aim to remove the Barrett's mucosa and allow regeneration of a squamous mucosa within a reflux free environment. A variety of options have been studied including:
- laser ablation,
- argon beam ablation,
- photodynamic therapy,
- multipolar electrocoagulation,
- heater probe.

Within the published studies, macroscopic complete regression has been reported in between 30 and 100% of patients. However, when biopsies have been taken from the neosquamous epithelium, glandular Barrett's mucosa can be found in up to 50% of cases. This mucosa can also progress through to dysplasia [4] and potentially carcinoma.

There is insufficient data to answer the question, how long do you have to follow a patient to be certain that the Barrett's esophagus has remained in remission following ablative therapy. Certainly macroscopic appearances alone are insufficient to answer this question and biopsies must be taken for histological evaluation. The published studies have relatively short follow-up periods (averaging less than 12 months) and as such do not help to answer the question.

Summary

From the literature base available to us currently, we cannot with any degree of precision answer the question. Barrett's esophagus probably progresses relatively slowly in it primary state and therefore after therapies aimed at ablation we should follow our patients for at least 5 years.

References

1. Haag S, Nandurkar S, Talley NJ. Regression of Barrett's esophagus: the role of acid suppression, surgery, and ablative methods. Gastrointestinal Endosc 1999;50(2):229-240.

2. Sharma P, Morales TG, Bhattacharyya A, Garewal HS, Sampliner RE. Squamous islands in Barrett's esophagus: what lies underneath? Am J Gastroenterol 1998;93(3):332-335.

3. DeMeester SR, DeMeester TR. Columnar mucosa and intestinal metaplasia of the esophagus:fifty years of controversy. Ann Surg 2000;231(3):303-321.

4. Michopoulos S, Tsibouris P, Bouzakis H, Sotiropolou M, Kralios M. Complete regression of Barrett's oesophagus with heater probe thermocoagulation; up to three years follow-up. Gastrointestinal Endosc 1999;50:165-172.


Publication date: August 2003 OESO©2015