What is the treatment of choice for Barrett’s esophagus with severe dysplasia?

Treatment of Barrett's Esophagus with Severe Dysplasia

Barrett's endoscopic therapy (BET) is the preferred treatment for Barrett's esophagus with high-grade dysplasia (HGD), rather than esophagectomy, follow-up endoscopy, or proton pump inhibitors alone. 1

Current Treatment Approach

The management of Barrett's esophagus with severe (high-grade) dysplasia has evolved significantly in recent years, with endoscopic approaches now being preferred over surgical intervention in most cases.

First-Line Treatment: Endoscopic Therapy

For patients with Barrett's esophagus with high-grade dysplasia, the treatment algorithm is:

1. Confirm the diagnosis:

   • Diagnosis should be confirmed by an experienced gastrointestinal pathologist 1
   • Repeat high-definition white-light endoscopy (HD-WLE) within 6-8 weeks to evaluate for visible lesions 1

2. Treatment of visible lesions:

   • Any visible lesions should be removed by endoscopic mucosal resection (EMR) 1, 2
   • EMR serves both diagnostic and therapeutic purposes 1

3. Treatment of flat dysplasia:

   • Barrett's endoscopic therapy (BET) is strongly recommended 1
   • Radiofrequency ablation (RFA) has shown high efficacy with complete eradication of dysplasia in approximately 90% of cases 1
   • RFA has been shown to reduce progression to esophageal cancer in randomized controlled trials 1

Role of Esophagectomy

While historically esophagectomy was considered the standard treatment for high-grade dysplasia, current evidence supports endoscopic approaches as first-line therapy:

• BET is preferred over esophagectomy for patients with HGD 1
• Esophagectomy should be reserved for specific situations:
  • Patients with submucosal esophageal adenocarcinoma (T1b) without low-risk features 1
  • Cases where endoscopic therapy has failed 2
  • Patients with high risk of cancer progression (incomplete endoscopic resection, lymphovascular invasion, or deep submucosal invasion >500 μm) 2

Follow-up After Treatment

After successful endoscopic eradication:

• Surveillance endoscopy with biopsies at 3,6, and 12 months, then annually thereafter 1
• Performed with high-definition white-light endoscopy 1

Why Endoscopic Therapy is Preferred Over Esophagectomy

The shift from esophagectomy to endoscopic therapy is based on:

1. Comparable efficacy: A meta-analysis of 870 patients found no significant difference in complete eradication of dysplasia rates between BET and esophagectomy 1

2. Lower morbidity: Adverse events were significantly lower in the BET group compared to surgery (RR, 0.38; 95% CI, 0.20-0.73; P = .004) 1

3. Similar survival outcomes: No differences in survival rates at 1,3, and 5 years between BET and esophagectomy 1

Common Pitfalls to Avoid

1. Inadequate pathological confirmation: Always have HGD confirmed by an experienced GI pathologist due to significant interobserver variability 1, 2

2. Missing visible lesions: Thorough examination with high-definition endoscopy is essential to identify and resect any visible abnormalities 1

3. Inappropriate patient selection for esophagectomy: While some older studies reported high rates (41-47%) of occult carcinoma in HGD patients 3, more recent guidelines recognize that most patients (70-80%) with HGD can be successfully treated with endoscopic eradication therapy 1

4. Failure to refer to specialized centers: BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually 1

In conclusion, while esophagectomy was historically considered the gold standard for Barrett's esophagus with high-grade dysplasia, current evidence strongly supports Barrett's endoscopic therapy as the preferred first-line treatment due to its comparable efficacy, lower morbidity, and similar long-term outcomes.