From the Guidelines
The treatment of choice for Barrett’s esophagus with severe dysplasia is endoscopic resection of visible oesophageal lesions as first-line treatment, followed by endoscopic ablation of any residual Barrett’s oesophagus. This approach is based on the most recent guidance from the National Institute for Health and Care Excellence (NICE) published in 2024 1. According to this guidance, endoscopic resection is recommended as the first-line treatment for people with high-grade dysplasia, which includes severe dysplasia.
The NICE guidance outlines the following key points for managing Barrett’s oesophagus with dysplasia:
- Offer endoscopic resection of visible oesophageal lesions as first-line treatment to people with high-grade dysplasia.
- Offer endoscopic ablation of any residual Barrett’s oesophagus to people with high-grade dysplasia after treatment with endoscopic resection. This approach prioritizes minimizing the risk of progression to adenocarcinoma while also considering the potential risks and benefits of different treatment options.
While esophagectomy (option b) is a definitive treatment for severe dysplasia, it is not the first-line treatment recommended by the NICE guidance for all cases of high-grade dysplasia. Endoscopic therapies, including radiofrequency ablation and endoscopic mucosal resection, are increasingly used in select cases and are recommended by the NICE guidance as the primary treatment for high-grade dysplasia. Other options like follow-up endoscopy and biopsy (option a), Nissen fundoplication (option c), or proton pump inhibitors (option d) may be useful adjuncts but are insufficient as primary treatments for severe dysplasia.
From the Research
Treatment Options for Barrett's Esophagus with Severe Dysplasia
- The treatment of choice for Barrett's esophagus with severe dysplasia is a topic of discussion among medical professionals, with various options available, including:
- Esophagectomy: a surgical procedure to remove the esophagus, which is considered the most effective treatment for eradicating the neoplastic epithelium 2, 3
- Endoscopic ablative therapies: such as endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA), which can be used to remove the affected tissue and prevent progression to cancer 4, 5
- Endoscopic surveillance: regular monitoring of the esophagus to detect any changes or progression to cancer, which may be suitable for patients who are not candidates for surgery or ablative therapies 4, 6
- Esophagectomy is considered the treatment of choice for patients with Barrett's esophagus and high-grade dysplasia who are healthy and have a reasonable life expectancy 3
- However, esophagectomy is a major surgical procedure with significant morbidity and mortality, and alternative treatments such as endoscopic ablative therapies and surveillance may be considered for patients who are not candidates for surgery or have a high risk of complications 2, 6, 5
Considerations for Treatment
- The natural history of Barrett's esophagus with high-grade dysplasia is not well understood, and the risk of progression to cancer is significant 4
- The choice of treatment depends on various factors, including the patient's overall health, the extent of the disease, and the presence of any comorbidities 3, 6
- A multidisciplinary approach, involving gastroenterologists, surgeons, and other healthcare professionals, is essential for determining the best course of treatment for each patient 2, 5