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Meta-Analysis
. 2010 Jan 20;2010(1):CD004060.
doi: 10.1002/14651858.CD004060.pub2.

Treatment for Barrett's oesophagus

Jonathan Re Rees  1 , Pierre Lao-Sirieix, Angela Wong, Rebecca C Fitzgerald
Affiliations
Meta-Analysis

Treatment for Barrett's oesophagus

Jonathan Re Rees et al. Cochrane Database Syst Rev. .

Retraction in

  • Treatment for Barrett's oesophagus.
    Rees JR, Lao-Sirieix P, Wong A, Fitzgerald RC. Rees JR, et al. Cochrane Database Syst Rev. 2021 Mar 4;3(3):CD004060. doi: 10.1002/14651858.CD004060.pub3. Cochrane Database Syst Rev. 2021. PMID: 33661543 Free PMC article.

Abstract

Background: Treatments for Barrett's oesophagus, the precursor lesion of adenocarcinoma, are available but whether these therapies effectively prevent the development of adenocarcinoma, and in some cases eradicate the Barrett's oesophagus segment, remains unclear.

Objectives: To summarise, quantify and compare the efficacy of pharmacological, surgical and endoscopic treatments for the eradication of dysplastic and non-dysplastic Barrett's oesophagus and prevention of these states from progression to adenocarcinoma.

Search strategy: We searched CENTRAL (The Cochrane Library 2004, issue 4), MEDLINE (1966 to June 2008) and EMBASE (1980 to June 2008).

Selection criteria: Randomised controlled trials (RCTs) comparing medical, endoscopic or non-resectional surgical treatments for Barrett's oesophagus. The primary outcome measures were complete eradication of Barrett's and dysplasia at 12 months, and reduction in the number of patients progressing to cancer at five years or latest time point.

Data collection and analysis: Three authors independently extracted data and assessed the quality of the trials included in the analysis.

Main results: Sixteen studies, including 1074 patients, were included. The mean number of participants in the studies was small (n = 49; range 8 to 208). Most studies did not report on the primary outcomes. Medical and surgical interventions to reduce symptoms and sequelae of gastro-oesophageal reflux disease (GORD) did not induce significant eradication of Barrett's oesophagus or dysplasia. Endoscopic therapies (photodynamic therapy (PDT with aminolevulinic acid or porfimer sodium), argon plasma coagulation (APC) and radiofrequency ablation (RFA)) all induced regression of Barrett's oesophagus and dysplasia. The data for photodynamic therapy were heterogeneous with a mean eradication rate of 51% for Barrett's oesophagus and between 56% and 100% for dysplasia, depending on the treatment regimens. The variation in photodynamic therapy eradication rates for dysplasia was dependent on the drug, source and dose of light. Radiofrequency ablation resulted in eradication rates of 82% and 94% for Barrett's oesophagus and dysplasia respectively, compared to a sham treatment. Endoscopic treatments were generally well tolerated, however all were associated with some buried glands, particularly following argon plasma coagulation and photodynamic therapy, as well as photosensitivity and strictures induced by porfimer sodium based photodynamic therapy in particular.

Authors' conclusions: Despite their failure to eradicate Barrett's oesophagus, the role of medical and surgical interventions to reduce the troubling symptoms and sequelae of GORD is not questioned. Whether therapies for GORD reduce the cancer risk is not yet known. Ablative therapies have an increasing role in the management of dysplasia within Barrett's and current data would favour the use of radiofrequency ablation compared with photodynamic therapy. Radiofrequency ablation has been shown to yield significantly fewer complications than photodynamic therapy and is very efficacious at eradicating both dysplasia and Barrett's itself. However, long-term follow-up data are still needed before radiofrequency ablation can be used in routine clinical care without the need for very careful post-treatment surveillance. More clinical trial data and in particular randomised controlled trials are required to assess whether or not the cancer risk is reduced in routine clinical practice.

PubMed Disclaimer

Conflict of interest statement

Jonathan Rees, Pierre Lao‐Sirieix and Rebecca Fitzgerald are funded by the Medical Research Council.

Jonathan Rees has also received research funding awards from the Royal College of Surgeons of Edinburgh and Cancer Research UK.

Rebecca Fitzgerald has occasionally acted as a consultant to Astra Zeneca and has research collaboration with Merck and GlaxoSmithKline.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Omeprazole vs histamine type 2 receptor antagonists, Outcome 1 Reduction in length (cm) of Barrett's oesophagus at 12 months.
1.2
1.2. Analysis
Comparison 1 Omeprazole vs histamine type 2 receptor antagonists, Outcome 2 Reduction in area (%) of Barrett's oesophagus at 12 months.
2.1
2.1. Analysis
Comparison 2 Celecoxib vs placebo, Outcome 1 Mortality.
2.2
2.2. Analysis
Comparison 2 Celecoxib vs placebo, Outcome 2 Any serious drug reactions.
3.1
3.1. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
3.2
3.2. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 2 Progression to cancer at latest possible time point.
3.3
3.3. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 3 Any complication.
3.4
3.4. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 4 Complete eradication of Barrett's oesophagus at 12 months.
3.5
3.5. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 5 Numbers progressing to dysplasia from intestinal metaplasia.
3.6
3.6. Analysis
Comparison 3 Anti‐reflux surgery vs omeprazole, Outcome 6 Complete eradication of dysplasia (at 5‐year follow up).
4.1
4.1. Analysis
Comparison 4 Nd‐YAG laser therapy vs omeprazole, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
4.2
4.2. Analysis
Comparison 4 Nd‐YAG laser therapy vs omeprazole, Outcome 2 Any complication.
5.1
5.1. Analysis
Comparison 5 Argon plasma coagulation vs no treatment after anti‐reflux surgery, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
5.2
5.2. Analysis
Comparison 5 Argon plasma coagulation vs no treatment after anti‐reflux surgery, Outcome 2 Complete eradication of Barrett's oesophagus at 12 months.
5.3
5.3. Analysis
Comparison 5 Argon plasma coagulation vs no treatment after anti‐reflux surgery, Outcome 3 Presence of buried subsquamous Barrett's glands.
6.1
6.1. Analysis
Comparison 6 Argon plasma coagulation vs multipolar electrocoagulation, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
6.2
6.2. Analysis
Comparison 6 Argon plasma coagulation vs multipolar electrocoagulation, Outcome 2 Any complication.
6.3
6.3. Analysis
Comparison 6 Argon plasma coagulation vs multipolar electrocoagulation, Outcome 3 Mortality.
6.4
6.4. Analysis
Comparison 6 Argon plasma coagulation vs multipolar electrocoagulation, Outcome 4 Control of acid reflux.
7.1
7.1. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
7.2
7.2. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 2 Any serious drug reactions.
7.3
7.3. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 3 Any complication.
7.4
7.4. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 4 Mortality.
7.5
7.5. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 5 Reduction in length (cm) of Barrett's oesophagus at 12 months.
7.6
7.6. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 6 Persistence of sub‐squamous glands.
7.7
7.7. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 7 Complete eradication of Barrett's oesophagus at 12 months.
7.8
7.8. Analysis
Comparison 7 Photodynamic therapy vs argon plasma coagulation, Outcome 8 Eradication of dysplasia at 12 months.
8.1
8.1. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 1 Any reduction/reversal of Barrett's oesophagus/dysplasia at 12 months.
8.2
8.2. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 2 Progression to cancer at latest possible time point.
8.3
8.3. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 3 Any serious drug reactions.
8.4
8.4. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 4 Any complication.
8.5
8.5. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 5 Mortality.
8.6
8.6. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 6 Reduction in length (cm) of Barrett's oesophagus at 12 months.
8.7
8.7. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 7 Reduction in area (%) of Barrett's oesophagus at 12 months.
8.8
8.8. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 8 Numbers progressing to dysplasia from intestinal metaplasia.
8.9
8.9. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 9 Complete eradication over the course of the study (5 years).
8.10
8.10. Analysis
Comparison 8 Photodynamic therapy versus omeprazole, Outcome 10 Complete eradication of dysplasia.
9.1
9.1. Analysis
Comparison 9 5‐ALA vs photofrin, Outcome 1 Eradication of high‐grade dysphagia.
9.2
9.2. Analysis
Comparison 9 5‐ALA vs photofrin, Outcome 2 Strictures.
10.2
10.2. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 2 Progression to cancer at latest possible time point.
10.3
10.3. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 3 Any complication.
10.4
10.4. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 4 Complete eradication of Barrett's oesophagus at 12 months.
10.5
10.5. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 5 Numbers progressing to dysplasia from intestinal metaplasia.
10.6
10.6. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 6 Complete clearance of dysplasia.
10.7
10.7. Analysis
Comparison 10 Radiofrequency ablation vs sham, Outcome 7 Numbers progressing to dysplasia from intestinal metaplasia.
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References

References to studies included in this review

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Johnston 2005 {published data only}
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Jung 2003 {published data only}
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Kamolz 2003 {published data only}
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Kashtan 2002 {published data only}
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Kaur 2002 {published data only}
    1. Kaur BS, Khamnehei N, Iravani M, Namburu SS, Lin O, Triadafilopoulos G. Rofecoxib inhibits cyclooxygenase 2 expression and activity and reduces cell proliferation in Barrett's esophagus. Gastroenterology 2002;123(1):60‐7. - PubMed
Keeley 2007 {published data only}
    1. Keeley SB, Pennathur A, Gooding W, Landreneau RJ, Christie NA, Luketich J. Photodynamic therapy with curative intent for Barrett's esophagus with high grade dysplasia and superficial cancer. Annals of Surgical Oncology 2007;14(8):2406‐10. - PubMed
Krska 2002 {published data only}
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Lanas 2007 {published data only}
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Montgomery 2002 {published data only}
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Morris 2001 {published data only}
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Niemantsverdriet 199 {published data only}
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O'Riordan 2004 {published data only}
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Oelschlager 2003 {published data only}
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Oleynikov 2003 {published data only}
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Olliver 2003 {published data only}
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Ormsby 2002 {published data only}
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Ortiz 1996b {published data only}
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Pacifico 2003 {published data only}
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Pagani 2003 {published data only}
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Panjehpour 2000 {published data only}
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Panjehpour 2008 {published data only}
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Peters 1999b {published data only}
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Peters 2000 {published data only}
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Ponce 2003 {published data only}
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Pouw 2008 {published and unpublished data}
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Pouw 2008b {published data only}
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Prasad 2007 {published data only}
    1. Prasad GA, Wang KK, Buttar NS, Wongkeesing LM, Lutzke LS, Borkenhagen LS. Predictors of stricture formation after photodynamic therapy for high‐grade dysplasia in Barrett's esophagus. Gastrointestinal Endoscopy 2007;65(1):60‐6. - PubMed
Ragunath 2003 {published data only}
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Robinson 2002 {published data only}
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Sampliner 2002 {published data only}
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Smith 2007 {published data only}
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