Barrett Esophagus
Paraesophageal Hernia and Barrett Esophagus

Video Endoscopic Sequence 1 of 13.

Paraesophageal Hernia and Barrett Esophagus.

This is the case of a 63 year-old woman that has been suffering of long-standing reflux diseas.

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Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Video Endoscopic Sequence 2 of 13.

Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Hiatal hernias may be classified into one of four types. Type I (sliding hiatal hernia) in which there is a migration of the esophago-gastric junction above the diaphragm into the thorax is the most common.

Type II is a true paraesophageal hernia in which the stomach herniates into the thorax, but the esophago-gastric junction remains fixed in its normal anatomic location below the diaphragm.
Type III (mixed paraesophageal hernia) is a combination of a sliding hiatal hernia with some or all of the stomach herniating above the esophago-gastric junction.

Type IV are those hiatal hernias which include abdominal viscera and/or solid organs within the hernia sac.

Rarely, a parahiatal hernia, where gastric herniation occurs through a diaphragmatic defect separate from the hiatus, may be seen.




Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Video Endoscopic Sequence 3 de 13.

Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Sliding hiatal hernia.

The patient has also a complex hiatal hernia.

 

 


Barrett Esophagus.

Video Endoscopic Sequence 4 of 13.

Barrett Esophagus.

The Barrett's epithelium is recognizable as salmon colored esophageal mucosa that contrasts with the pearly white appearance of the normal esophageal squamous mucosa.

The length of Barrett's epithelium is conventionally measured by subtracting the distance from the incisors to the squamocolumnar junction from the distance to the top of the gastric folds.

The gastric folds are apparent here. The squamocolumnar junction is seen here.


Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Video Endoscopic Sequence 5 of 13.

Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Endoscopic view of Tongues of Barrett's metaplasia.


Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Video Endoscopic Sequence 6 of 13.

Endoscopy of Paraesophageal Hernia and Barrett Esophagus.

Inside the Paraesophageal hernia, there are fibers accumulated.

 

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Video Endoscopic Sequence 7 of 13.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Endoscopic Ablation of Barrett's esophagus with argon plasma coagulator.

Management of Barrett esophagus is still a clinical challenge Although the incidence of cancer appears to be low, occurring in 0.5% of patients with Barrett esophagust.

Argon plasma coagulation

Video Endoscopic Sequence 8 of 13.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Argon plasma coagulation is one of several techniques
used to ablate Barrett's esophagus.

Argon plasma coagulation of Barrett's esophagus is safe and effective. The effects are durable, and buried glands may resolve with time. Long-term follow-up is required to assess the impact of argon plasma coagulation on cancer risk.

Barrett’s esophagus (BO) is undoubtedly associated with an increased risk of adenocarcinoma of the esophagus. Now that therapeutic endoscopy techniques have improved, it is therefore tempting to ablate Barrett’s intestinal metaplasia in order to decrease the risk of tumour development. However, ablation therapy is still controversial, especially for patients having no dysplasia, due to: their low risk of cancer; the risk associated with the technique of ablation; and the fact that we do not know if Barrett’s ablation will really decrease the risk of cancer in the long term in an individual patient.


Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Video Endoscopic Sequence 9 of 13.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Endoscopic ablation of Barrett's esophagus using high power setting argon plasma coagulation 90 watts.


The rationale for current ablative therapy began with the observation that destruction or ablation of intestinal metaplasia associated with acid suppression results in its rapid replacement by a squamous epithelium. Several groups of investigators have performed clinical studies evaluating the effectiveness of BO ablation associated with proton pump inhibitor (PPI) treatment. For patient having non-dysplastic BO without dysplasia, argon plasma coagulation (APC) has been the most popular technique. After 1–6 sessions, a success rate of BO eradication ranging from 42% to 98% was achieved. Chest pain was very frequent after treatment and other complications were unusual, although not negligible since they included strictures, fever,8 bleeding, or even perforation and death. More importantly for the long term usefulness of this therapy was the observation of persisting buried intestinal metaplasia under the squamous re-epithelialisation, which was observed in the first clinical trials.




Argon plasma coagulation of Barrett's esophagus.

Video Endoscopic Sequence 10 of 13.

Argon plasma coagulation of Barrett's esophagus.

APC treatment of Barrett's esophagus is simple, efficacious and safe. Reversal of Barrett's mucosa can be achieved by a few endoscopic sessions.

But long term follow-up studies on many patients are necessary to establish the frequency of endoscopic surveillance on the basis of recurrence or dysplasia evolution risk, in spite of APC treatment.

Argon plasma coagulation of Barrett's esophagus.

Video Endoscopic Sequence 11 of 13.

Argon plasma coagulation of Barrett's esophagus.

APC is a technique that delivers controlled monopolar electrocoagulation via a stream of ionized argon gas ignited by a high voltage discharged at the tip of a specialized flexible probe.

It is a noncontact ablative method with a predetermined depth of injury (approximately 2 mm) that is most often used for coagulation of bleeding surface lesions such as arteriovenous malformations.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Video Endoscopic Sequence 12 of 13.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Ablative therapy. The goal of ablative therapy is to destroy the Barrett epithelium to a sufficient depth to eliminate the intestinal metaplasia and allow regrowth of squamous epithelium.
A number of modalities have been tried, e.g. photodynamic therapy, argon plasma coagulation, multipolar electrocoagulation and various forms of lasers.

There is no direct evidence to suggest that there is a reduction in cancer risk in patients after mucosal ablation therapy.
Long term outcomes have been disappointing in terms of relapse after treatment, but this form of treatment is still considered to offer the prospect of developing improved intervention for the future.



Argon plasma coagulation therapy for ablation of Barrett’s esophagus

Video Endoscopic Sequence 13 of 13.

Argon plasma coagulation therapy for ablation of Barrett’s esophagus

A follow up endoscopy was performed six months after the APC ablation.

Due to the APC ablation the tongues have been shortened, but there is Barrett epithelium yet, a new session of APC will be programmed.

 

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