Cryotherapy

January 29th, 2009

Another option for ablation of Barrett’s esophagus with dysplasia is cryotherapy. 

Cryotherapy works by spraying freezing liquid or gas onto the lining of the esophagus.  The depth of the freezing effect is 1-2 mm.  Cryotherapy has been used in other parts of the gastrointestinal tract, such as the stomach in patients with gastric antral vascular ectasia (watermelon stomach), or in the rectum to treat radiation proctitis.  

There are currently two different types of cryotherapy available for treatment of Barrett’s esophagus.  Each system uses a regular upper endoscope and has a thin tube that is passed through the endoscope and out the tip.  Then cryospray, either liquid nitrogen or freezing carbon dioxide, is sprayed onto the lining of the esophagus.  When cryotherapy is used, the cells lining the esophagus are frozen, which damages them.  The body then makes an inflammatory reaction, gets rid of the damaged cells, and new (normal) esophageal mucosa covers the area where the Barrett’s used to be. 

There are a few papers describing how cryotherapy works. More recently, several research abstracts were presented at Digestive Disease Week 2008, an international gastroenterology research meeting.  One study used the carbon dioxide cryotherapy system and the other used the liquid nitrogen based system.  Both studies looked at patients with high grade dysplasia or tiny (intramucosal) cancers. 

In the liquid nitrogen cryotherapy study, 32 patients participated. For the 20 patients with HGD, 16 had at least a partial response (improvement) after cryotherapy and 50% had complete resolution of their HGD.  For the patients with intramucosal cancer, 6 of 9 had at least a partial response, and 1/3 had complete resolution of their intramucosal cancer. The average number of cryotherapy sessions in the study was 4. The complications included 3 esophageal strictures, 1 lip ulcer, and 1 stomach perforation. 

In the carbon dioxide cryotherapy study, 33 patients participated. The average number of treatments for each patient was 3. 79% of patients had a reduction in the amount of dysplasia and BE.  21% had a complete response, with complete elimination of dysplasia and BE.  3 patients in the study with intramucosal cancer had complete resolution of their cancer after cryotherapy treatment.  One patient had transient mild heartburn after cryotherapy, but no strictures or perforations occurred.

So what’s the take home message about cryotherapy?  It seems to be effective for treating Barrett’s esophagus with dysplasia, but there aren’t as many papers published about it yet.  The two studies mentioned above are ongoing and the final results haven’t been published, so the final outcome of the studies might be better (or possibly worse).  At this point, there are more studies published about photodynamic therapy and radiofrequency ablation for treating Barrett’s esophagus with dysplasia.  So cryotherapy one of the choices for treatment of Barrett’s with dysplasia and worth discussing with your own gastroenterologist.

If you think you may be interested in cryotherapy treatment, there are several ongoing research studies that can be found on clinicaltrials.gov and by searching the internet. 

Here are the references for the 2 cryotherapy studies mentioned above. 

Dumot JA, et al. Results of Cryospray Ablation for Esophageal High Grade Dysplasia (HGD) and Intramucosal Cancer (Imca) in High Risk Non-Surgical Patients.  Gastrointestinal Endoscopy, Volume 67, Issue 5, April 2008, Page AB176

Canto MI, et al. Low Flow CO2-Cryotherapy for High Risk Barrett’s Esophagus (BE) Patients with High Grade Dysplasia and Early Adenocarcinoma: A Pilot Trial of Feasibility and Safety a Pilot Trial of Feasibility and Safety.  Gastrointestinal Endoscopy, Volume 67, Issue 5, April 2008, Pages AB179-AB180

 -posted by Kerry Dunbar, MD

Radiofrequency Ablation (RFA) – Barrx

December 17th, 2008

One of the newer treatments for Barrett’s esophagus with dysplasia is radiofrequency ablation, also sometimes referred to as Barrx (the name of the company), or Halo (the name of the specific treatment).  Several people have asked questions about Barrx, so here’s some information.

How it works

Halo 360 – Upper endoscopy is performed and the length of the Barrett’s esophagus is measured. A special ‘sizing balloon’ is used to figure out the width of the esophagus where the BE is located.  Once the diameter of the esophagus is known, a special catheter with the ablation balloon on it is passed into the esophagus. There are 3 cm of electrodes on the balloon which are placed in the area of the BE to be treated. When the balloon is inflated, the electrodes touch the wall of the esophagus and energy is released.  The release of the energy creates a shallow burn, which destroys the Barrett’s esophagus without harming the tissue underneath. The treated area is then gently cleaned with a plastic cap on the end of the endoscope to remove any loose tissue. Then the BE is treated a second time with the RFA balloon. 

Circumferential RFA is most often performed with longer BE, particularly when the BE is present on all the walls of the esophagus. 

Halo 90 – A small device that looks like a paddle (about 2 cm by 1 cm in size) is placed on the end of a regular endoscope.  An upper endoscopy is then performed and the paddle is placed on areas of BE that to be treated.  The endoscopist then steps on a pedal, and energy is released, making a shallow burn in the area.  Each area of BE is treated twice, then the mucosa is cleaned with the paddle. The same areas are then treated 2 more times with the Halo90 during the same procedure. 

Halo90 is typically used in patients with small amounts of BE, such as tongues or islands of Barrett’s.  

Complications

Chest discomfort may occur after the procedure. Other possible complications include lacerations of the esophageal mucosa, which is like a shallow tear or cut which may bleed.  Some patients have had difficulty swallowing after the procedure and rarely patients will develop a stricture that needs dilation with a special balloon.  Perforation, or tearing the wall of the esophagus, is a risk, but so far no studies have been published showing a perforation during RFA.

What’s published?

There is alot of interest in ablation of Barrett’s esophagus and several ongoing research studies.  Here are a few of the published studies using RFA in dysplasia:

At Digestive Disease Week 2008, an international gastroenterology meeting, the interim results for a randomized, multicenter, sham-controlled trial of RFA were presented.  All the patients in the study had BE with HGD or LGD.  The patients were randomized (randomly assigned) to either RFA or a sham (fake) RFA.  Halo 360 and Halo 90 were performed to treat the BE and dysplasia. 

At the time of the presentation in May 2008, 127 patients had been treated.  The average number of sessions needed to treat BE with dysplasia was 3.5.  67% of patients with HGD had complete eradication of dysplasia compared to no patients who received the sham treatment.  96% of patients with LGD had complete eradication of dysplasia with RFA.  Looking at complete eradication of the BE, 60% of patients with HGD and 83% of patients with LGD had no BE left after treatment with RFA.  1 patient had a stricture treated with dilation and there were no esophageal perforations.  The study’s expected completion date was summer 2008, so complete results should be available soon. (1) 

A US Multicenter registry study of RFA was published in July 2008, which looked back at the records of 142 patients with BE-HGD at 16 different academic hospitals.  RFA was performed in all the patients using the Halo360.  In this study, patients had 1 to 2 ablation sessions.  2 patients had HGD after ablation.  Of the patients in the study who had follow up biopsies, complete eradication of HGD was seen in 90% of patient.  Complete eradication of all dysplasia (including LGD) was seen in 81%. Complete eradication of all Barrett’s esophagus occurred in 54% of patients.  One patient in the study developed an esophageal stricture (narrowing) which was treated with esophageal dilation. (2)

Another study looked at RFA in patients with early cancer, high grade dysplasia (HGD), or low grade dysplasia (LGD).  44 patients were in the study and 31 patients had endoscopic mucosal resection (EMR) of nodular BE.  The patients then had ablation of the remaining BE using the Halo360 or Halo90 system.  At the end of the study, the BE and dysplasia was completely gone in 98% of the patients (43 of 44).  Follow up at 21 months showed no recurrence of dysplasia in the patients. (3)

Who Should Consider RFA?

Most of the research done with RFA has been targeted to patients with Barrett’s esophagus and dysplasia. The response to treatment is very good in most of the studies, and is a reasonable option to consider for treatment.  For patients without dysplasia, the use of RFA is not as clear, which will be addressed in a separate post. 

Here are the references for the 3 studies discussed above:

  1. Shaheen NJ, Sharma P, Overholt BF, et al.  A randomized, multicenter, sham-controlled trial of radiofrequency ablation for subjects with Barrett’s esophagus containing dysplasia: interim results of the AIM dysplasia trial.  Gastroenterology, Volume 134, Issue 4, Supplement 1, April 2008, Pages A-37
  2. Ganz RA, Overholt BF, Sharma VK, et al.  Circumferential ablation of Barrett’s esophagus, that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointestinal Endoscopy 2008, vol 68(1), pp 35-40. 
  3. Pouw RE, Gondrie JJ, et al. Eradication of Barrett’s esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 2008, vol 12, pp 1627-37.

A letter from Sherry Skipper

November 13th, 2008

3 November 2008

Dear Dr. Montgomery,

Thank you for your prompt reply to my inquiry regarding donations in the memory of Philippe (Phil) Ross. I know that you are responding to each donor with a thank you note; that is a wonderful gesture. I also want to express my gratitude to each of them for honoring Phil.

I know that with the relatively low numbers of cases of esophageal cancer diagnosed each year, it is considered an “orphan” disease and doesn’t get the attention that more widespread cancers do. Recently, I read that the number of cases of esophageal cancer diagnosed yearly is increasing, especially adenocarcinoma, the form of esophageal cancer that Phil had. Our hospice nurse, who has been in nursing for 30 plus years and in hospice for the last 18 years, told us that she is seeing an increase in the number of patients in the hospice system in Denver with esophageal cancer.

I hope that some of the research effort taking place in esophageal cancer is outreach and education to doctors. Phil woke me in the middle of the night in late 2003 with excruciating pain in his upper abdominal area and drove himself to the emergency room to be seen. Phil was not a person to visit the emergency room; for him to seek relief there meant it was serious. However, he was treated for an episode of acid reflux with the usual medications. There was no examination beyond an oral account of his symptoms and the monitoring of standard vital signs. I understand that triage nurses and emergency room doctors and nurses see many patients, some with gastric distress, but I can’t keep myself from thinking that if someone had taken the symptoms more seriously, he would be here now. He was a member of the population most susceptible for esophageal adenocarcinoma, a white male in his fifties. If I knew then what I do now, I would have insisted on further tests. He was diagnosed with cancer at the gastroesophageal junction in October 2005 while on a teaching and research sabbatical at a university in Aveiro, Portugal. At that time, he was in apparent excellent health; he worked out regularly at the University’s gym and ran about 30 miles per week. He consulted a doctor there when he started having difficulty swallowing. By then, the cancer was stage IV. When I read the prognosis on medical websites, my world was shattered. When Phil returned to the U.S. for follow-up and treatment, he gave me the option of not being involved in his care, knowing that it was going to be hard and that the likely outcome was a short survival time. I told him then and throughout his treatment that we were a team; I couldn’t imagine not being there to love and support him and act as his caretaker and health care advocate. Today is the four month anniversary of Phil’s death and I still can’t believe that it happened. He fought such a brave fight – a cliché – but it is true. He suffered through chemotherapy, radiation, radical surgery and visits to the emergency room with systemic infections, a suspected lung infection and bowel impactions. He lost the ability to do the things that he loved the most but never adopted a “poor me” attitude. Anything that we can do to keep other people and those who love them from going through this is an effort that deserves attention and support. I have enclosed a contribution today and will continue to contribute to your department when I am able – in recognition of ‘Team Phil’.

I hope for continued advances in detection and treatment from your department’s research.

With kind regards,
Sherry Skipper

Barrett’s Esophagus with High Grade Dysplasia

November 5th, 2008

We’ve had some questions about high grade dysplasia in Barrett’s esophagus, so here’s some information that may be helpful.

The lifetime risk of esophageal cancer from Barrett’s esophagus is low, probably on the order of 5% or less.  Surveillance programs with regular upper endoscopy seem to help detect dysplasia before it progresses to cancer. 

So what if you do have high grade dysplasia (HGD)?  HGD occurs when the Barrett’s esophagus cells accumulate mutations and lose their normal shape and pattern.  HGD isn’t cancer, but it is the step before cancer. The risk of developing esophageal cancer from HGD has been looked at in several studies and ranges from 20% to 50%.  

With HGD, there are several options for evaluation and treatment

 Evaluation

  1. Have your slides reviewed by an expert GI pathologist – to make sure the biopsies show HGD and not cancer or low grade dysplasia (LGD)
  2. Have repeat endoscopy with more biopsies to determine if there’s just one area with HGD or multiple areas of HGD (multifocal HGD)
  3. Some gastroenterologists like to perform an endoscopic ultrasound for any patient diagnosed with BE-HGD.  This is done to look for signs of cancer, such as enlarged lymph nodes or invasion of tissue through the wall of the esophagus.  However, experts disagree about whether this is necessary.  There have been a few studies that EUS isn’t that helpful for HGD.  But EUS is important for staging cancers in Barrett’s esophagus.

Treatment

There are several options for treatment and there’s no one right answer for every patient.  Often, patients may need a combination of the therapies below to treat their HGD.  Other health issues and patient preferences play a role in choosing the right treatment.

  1. Continued surveillance – repeating an EGD every 3 months to look for cancer.  This is an option for patients who don’t want (or are too unhealthy) for other therapies.  Also, continued surveillance is important for anyone treated for HGD with any of the therapies listed below, to make sure new areas of HGD haven’t arisen. 
  2. High dose proton pump inhibitor therapy – generally given twice daily.  It doesn’t cure HGD, but can help reduce inflammation and make biopsies easier to interpret.  There are some studies that show regression of low grade dysplasia with PPI therapy.
  3. Esophagectomy – surgical removal of the esophagus.  This procedure gets rid of all the BE and dysplasia.  The esophagus is removed and the stomach is pulled up into the chest or a piece of large intestine is used to make a new esophagus. This is very effective for getting rid of HGD, but is a major surgery and the complication rate varies.  It’s important to choose a surgeon who does many esophagectomy procedures as they tend to have lower complication rates.
  4. Endoscopic mucosal resection (EMR) – useful for removing small areas of the esophageal mucosa that contain HGD.  EMR is often used to remove bumpy areas of HGD. 
  5. Photodynamic therapy – A light-sensitizing medication, porfimer sodium, is injected intravenously.  Then a special laser fiber is inserted through the endoscope to the area of BE and dysplasia. The light from the laser causes a photochemical reaction with the porfimer sodium, which destroys the mucosa.  Patients who have PDT are photosensitive for several weeks and are advised to avoid the sun. 
  6. Radiofrequency ablation –  A special balloon or small paddle attached to the endoscope are used to burn away a thin layer of the esophageal mucosa, getting rid of the HGD in the Barrett’s esophagus.  This is one of the newer treatment options for BE HGD.
  7. Cryotherapy – Freezing liquid nitrogen or carbon dioxide is sprayed onto the esophageal mucosa, freezing the BE and HGD.  This is another newer treatment option for BE HGD.

If you have any questions about treatment of HGD, talk with your gastroenterologist about the different options to see which treatment would be best for you. 

posted by Kerry Dunbar, MD

Research on nanocurry featured on local CBS news

November 1st, 2008

Dear All

As I discussed in my first post, one of the areas of research in my laboratory involves testing the use of curcumin as an anticancer and chemopreventive agent. Curcumin is derived from turmeric, which for those of you who have eaten Indian food, know as the spice that gives curry its yellow color. Curcumin is known to be a potent anti-cancer agent, but its use in cancer (as well as in many other diseases like Alzheimer disease) has been limited because the drug does not get absorbed from the GI tract. We have developed a nanoparticle (nano = very small, about 10,000 times smaller than the size of a pin-head) that can encapsulate curcumin and help deliver it into the body. This product, which we call “nanocurcumin” (or nanocurry) is being tested in the laboratory and hopefully will be in the clinic in a couple of years, ready for human use.

I am very excited by this research for several reasons:

First, curcumin has been a component of diet for many centuries, so this is relatively safe as a “drug”.

Second, nanocurcumin is able to get hundred fold higher levels of curcumin in the blood compared to the free drug, a big advancement by any strecth.

Third, in addition to being useful as an anti-cancer agent, curcumin also works in chemoprevention. Once this drug is approved for human use, we hope to perform a trial in Barrett esophagus patients in collaboration with the clinical team at Hopkins to see if nanocurcumin can help prevent progression in this disease. This study is however, a few years away.

The local CBS affiliate in Baltimore (WJZ13) did a story on nanocurcumin. You can read the story and watch the video by clicking here:

anirban on the news

Anirban Maitra, MD

Guidelines for Surveillance of Barrett’s Esophagus

October 30th, 2008

One of our blog visitors had a question about how often endoscopy should be performed in patients with Barrett’s esophagus.

With Barrett’s esophagus, studies have shown that surveillance endoscopy (EGD) for dysplasia improves survival by detecting small esophageal cancers earlier in their course. Because of this, several national gastroenterology societies have published guidelines for the surveillance of Barrett’s esophagus. Most recently, the American College of Gastroenterology updated their Barrett’s esophagus guidelines. The guidelines were created using the available published research on BE and dysplasia about the risk of progression to cancer and surveillance of BE.

Here are the 2008 ACG BE Surveillance Guidelines:

For BE with no dysplasia

  • a second EGD with biopsies within a year to confirm there is no dysplasia
  • If both EGDs with biopsies show no dysplasia, then repeat EGD with biopsy is recommended every 3 years

For BE with low grade dysplasia (LGD)

  • Have the pathology slides showing LGD read by an expert pathologist (to make sure no high grade dysplasia (HGD) is present
  • Repeat EGD with biopsies within 6 months to reassess for dysplasia
  • If no dysplasia is present on repeat EGD, then yearly EGD with biopsy is recommended until two years worth of EGDs show no dysplasia

For BE with high grade dysplasia (HGD)

  • Have the pathology slides showing HGD read by an expert pathologist to confirm the diagnosis
  • If the HGD is found in a mucosal irregularity (i.e. and ulcer, a nodule, a bumpy area of the esophagus), then endoscopic mucosal resection (EMR) is recommended to remove it
  • EGD with biopsies should be repeated within 3 months to look for HGD and tiny cancers. Intervention should be performed based on the biopsy results and tailored to the patient.
  • Possible interventions for HGD include – esophagectomy, endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, ablation using cryotherapy

These are the newest guidelines and they’re widely used, but some gastroenterologists do screen more frequently, so talk with your gastroenterologist to see what he/she recommends.

The reference for the ACG Guidelines is:

Wang, KK and Sampliner, RE. Updated guidelines 2008 for the diagnosis, surveillance, and therapy of Barrett’s esophagus. American Journal of Gastroenterology 2008, volume 103, pages 788-797.

posted by Kerry Dunbar, MD

An Introduction to Barrett Esophagus Research

October 28th, 2008

Dear Reader,

My name is Anirban Maitra, and I am an Associate Professor of Pathology and Oncology at Johns Hopkins University School of Medicine. I completed my residency in Pathology at the University of Texas Southwestern Medical Center (same place as Dr. Kerry Dunbar!) and came to Johns Hopkins in 2001 for a combined clinical/research fellowship in Gastrointestinal Pathology. I learned my GI “chops” from Dr. Montgomery, who all of you know as a world expert on Barrett Esophagus. I joined the GI Pathology faculty in 2002 and besides doing diagnostic pathology (for example, reading biopsies on the microscope), I also run a laboratory with a focus on GI and pancreatic cancers. I was initiated into Barrett esophagus research thanks to Dr. Montgomery and my association with the wonderful clinical team at Hopkins (Drs. Dunbar, Wang and Canto). One of the first lessons I learnt in the laboratory is that it’s hard to perform cancer research in a vacuum. At the end of the day you need a highly committed multi-disciplinary team that includes gastroenterologists, pathologists, surgeons, radiologists, and basic scientists. We are very fortunate at Hopkins to have such a dedicated team in Barrett esophagus research. The guiding principle of any research conducted in my laboratory is simple – what we do needs to ultimately help the patient.

Over the next few weeks, I will introduce you to some of the exciting ongoing research in my laboratory centered on Barrett esophagus. Much of this work has been conducted through private philanthropy supported by families that came to us through the Barrett esophagus website. These private funds have helped support Dr. Hector Alvarez, a talented physician scientist from Chile, in my laboratory. Hector’s work is 100% dedictaed to Barrett esophagus and esophageal cancer research and we are thankful to the generous support of families that have allowed us to pursue this work in these times of curtailed federal (NIH) funding.

Please check back on this blog on a regular basis – we plan to have pictures and data to share (Dr. Montgomery has already shared some of this with you in a downloadable PowerPoint).

Cheers
Anirban Maitra, MD

Gastroenterology and Barrett’s Esophagus

October 24th, 2008

Welcome again to the Johns Hopkins Barrett’s esophagus blog! I’m Kerry Dunbar, MD and will also be posting new information about Barrett’s esophagus on the blog. I’m a gastroenterologist at Johns Hopkins and have a clinical and research interest in Barrett’s esophagus and Barrett’s-associated dysplasia.

I graduated from the University of Texas Southwestern Medical School in 2000 and have been at Johns Hopkins ever since. I completed my internal medicine residency in 2003 and spent a year as an assistant chief of service for the medicine residency program, which was a great opportunity to teach residents and medical students. Next came gastroenterology fellowship at Johns Hopkins, which included specialized training in clinical research and endoscopic techniques like confocal endomicroscopy, narrow band imaging, chromoendoscopy, endoscopic mucosal resection, cryotherapy, and endoscopic ultrasound. I joined the faculty in July and in addition to seeing patients with Barrett’s esophagus, also take care of patients with GERD, eosinophilic esophagitis, and other esophageal disorders.

There are two other faculty members at Hopkins who have a special interest in Barrett’s esophagus – Marcia Canto, MD, MHS and Jean Wang, MD. If you’re interested in finding out more about the gastroenterology division at Johns Hopkins, you can go here for more information: www.hopkins-gi.org.

An Introduction to Our Barrett’s Esophagus Research

October 23rd, 2008

The link below introduces several projects in progress in Dr. Anirban Maitra’s laboratory. Stay tuned for an introduction from Dr. Maitra himself. He is a talented scientist who won the Maryland 2006 Outstanding Young Scientist Award and the 2008 Ramzi Cotran Young Investigator Award from the United States and Canadian Academy of Pathology. This award was presented at the Academy’s annual meeting in Denver. The Young Investigator Award recognizes a body of work which has contributed significantly to the diagnosis and understanding of human disease.

Welcome to The New Johns Hopkins Barrett’s Esophagus Blog

October 20th, 2008


Welcome to the Johns Hopkins Barrett’s esophagus blog. Many have enjoyed our website and discussion boards [and we appreciate those of you who have drawn our attention to problems that have come up from time to time]. Our intention is to offer an educational forum about Barrett’s esophagus and its complications. Many who visit our site have learned about the very worst complication, esophagus cancer, which is a horribly deadly type of cancer when caught late. However, the good news is that many who have visited the site have learned about Barrett’s esophagus at a point when treatment is effective, such as at the “precancerous” stage (also called “dysplasia”). We are thrilled that several individuals have prompted loved ones to undergo screening after studying the site. However, the site was first posted in about 2000 and we realize we could do more to be consistently current, hence this blog.

Let me introduce myself and in the next few weeks, other members of the team with different expertise will also introduce themselves. I studied chemistry at Johns Hopkins as a college student from 1976-1980 and attended medical school at George Washington University from 1980-1984 and completed my residency at Walter Reed Army Medical Center [I was in the US Army from 1984 until late 1992]. After working at the Armed Forces Institute of Pathology and Georgetown University, I have been at Johns Hopkins since 1999. I am a pathologist, but not the type that is featured on CSI or other forensic programs. Most of my time is spent reviewing microscopic slides from biopsies from the gastrointestinal tract, and esophagus biopsies are a frequent type of sample! I work closely with gastroenterologists, oncologists, surgeons, and other pathologists and my title here is “Professor of Pathology and Oncology”. In the next few weeks, colleagues in other departments will introduce themselves, beginning with my colleagues Anirban Maitra, MBBS, who is a talented scientist in addition to being a diagnostic pathologist like I am, and Kerry Dunbar, MD, who is a terrific gastroenterologist. Before this happens, I would like to show some images of microscopic fields Barrett’s esophagus and dysplasia and introduce some of the research going on at Johns Hopkins. For example, I am very excited that a substance found in ordinary curry that we eat has potential as a treatment for esophagus cancer and our own Dr. Maitra has discovered a better way to deliver it to the cancer cells! Dr. Dunbar has been working on new endoscopic methods to better detect dysplasia in Barrett’s esophagus.

We are proud to note that we have received financial support from friends and family of Jerry D’Amato, “Phil” Ross, Roy Jeannotte, and many others. Kuwanna Dyer even did a charity sponsored running event and sent us a donation. These efforts have allowed for educational and scientific projects and we are grateful to everyone who has contributed.

This is how Barrett’s esophagus looks to the endoscopist (upper) and under the microscope (lower). This sample is from the esophagus of a 55 year old man.

This is what Barrett\'s esophagus looks like under the microscope.

The image above is taken at low magnification of an endoscopic mucosal resection sample that my colleague, Dr. Marcia Canto, performed.  There is high grade dysplasia that has been removed.  This patient did not need an esophagectomy.