Endoscopic therapy for Barrett’s esophagus and early esophageal cancer: Where do we go from here?

Abstract

Since Barrett’s esophagus is a precancerous condition, efforts have been made for its eradication by various ablative techniques. Initially, laser ablation was attempted in non-dysplastic Barrett’s esophagus and subsequently, endoscopic ablation using photodynamic therapy was used in Barrett’s patients with high-grade dysplasia who were poor surgical candidates. Since then, various ablative therapies have been developed with radiofrequency ablation having the best quality of evidence. Resection of dysplastic areas only without complete removal of entire Barrett’s segment is associated with high risk of developing metachronous neoplasia. Hence, the current standard of management for Barrett’s esophagus includes endoscopic mucosal resection of visible abnormalities followed by ablation to eradicate remaining Barrett’s epithelium. Although endoscopic therapy cannot address regional lymph node metastases, such nodal involvement is present in only 1% to 2% of patients with intramucosal adenocarcinoma in Barrett esophagus and therefore is useful in intramucosal cancers. Post ablation surveillance is recommended as recurrence of intestinal metaplasia and dysplasia have been reported. This review includes a discussion of the technique, efficacy and complication rate of currently available ablation techniques such as radiofrequency ablation, cryotherapy, argon plasma coagulation and photodynamic therapy as well as endoscopic mucosal resection. A brief discussion of the emerging technique, endoscopic submucosal dissection is also included.

Keywords: Endoscopic mucosal resection; Barrett’s esophagus; Dysplasia; Adenocarcinoma; Endoscopic therapy; Radiofrequency ablation

Core tip: Endoscopic treatment has become the standard of care for Barrett’s esophagus with dysplasia and/or early adenocarcinoma. The treatment primarily consists of resection of any visible lesions by either endoscopic mucosal resection or rarely, endoscopic submucosal dissection followed by ablation of metaplastic epithelium by one of the many available techniques (radiofrequency ablation being the most commonly used). While periodic surveillance is still required after complete eradication of intestinal metaplasia, these treatment modalities have proven to decrease the incidence of esophageal adenocarcinoma, improve the quality of life and are cost effective.