What is the management and treatment plan for Barrett's esophagus?

Management and Treatment Plan for Barrett's Esophagus

The management of Barrett's esophagus requires a structured approach including symptom control, endoscopic surveillance, and treatment of dysplasia or early cancer, with treatment decisions based on the degree of dysplasia and presence of visible lesions. 1

Initial Assessment and Patient Education

• Offer a clinical consultation to newly diagnosed patients to discuss cancer risk, surveillance plans, and symptom control 1
• Provide verbal and written information about the diagnosis, treatment options, and patient support groups 1
• After each surveillance procedure, provide an endoscopy report with a lay summary of findings and reference to ongoing symptom control 1

Symptom Control

• Follow NICE guidelines on interventions for gastroesophageal reflux disease (GORD) for symptom management 1
• Use acid-suppressant medication (such as proton pump inhibitors like omeprazole) to control reflux symptoms and optimize treatment in patients with dysplasia 2
• Do not offer anti-reflux surgery specifically to prevent progression to dysplasia or cancer 1

Surveillance Protocol

Endoscopic Technique

• Use high-resolution white light endoscopy with Seattle biopsy protocol for surveillance 1
• Ensure a minimum of 1-minute inspection time per cm of Barrett's esophagus length 3
• Document landmarks, the BE segment (one picture per cm), and the esophagogastric junction in retroflexed position 3
• Collect biopsies from all visible abnormalities and random four-quadrant biopsies every 2 cm of BE length 3

Surveillance Intervals

• For non-dysplastic Barrett's esophagus:

  • BE length ≥1 cm and <3 cm: repeat surveillance every 5 years 3
  • BE length ≥3 cm and <10 cm: repeat surveillance every 3 years 3
  • BE length ≥10 cm: refer to a BE expert center 3
  • Irregular Z-line/columnar-lined esophagus <1 cm: no routine biopsies or surveillance needed 3

• Consider discontinuing surveillance in patients who have reached 75 years of age or have a life expectancy less than 5 years 3

Management of Barrett's Esophagus with Dysplasia

Low-Grade Dysplasia (LGD)

• Offer radiofrequency ablation to patients with LGD diagnosed from biopsy samples taken at two separate endoscopies and confirmed by two gastrointestinal pathologists 1

Indefinite Dysplasia

• Consider endoscopic surveillance at 6-monthly intervals with dose optimization of acid-suppressant medication 1

High-Grade Dysplasia (HGD)

• Offer endoscopic resection of visible oesophageal lesions as first-line treatment 1
• Offer endoscopic ablation of any residual Barrett's esophagus after treatment with endoscopic resection 1
• For HGD without visible lesions, recommend endoscopic ablation to prevent progression to invasive cancer 3

Management of Stage 1 Oesophageal Adenocarcinoma

T1a Oesophageal Adenocarcinoma

• Offer endoscopic resection as first-line treatment 1
• Offer endoscopic ablation of any residual Barrett's esophagus after treatment 1
• Offer endoscopic follow-up to patients who have received endoscopic treatment 1

T1b Oesophageal Adenocarcinoma

• For patients fit for surgery and at high risk of cancer progression (e.g., incomplete endoscopic resection, lymphovascular invasion): offer oesophagectomy 1
• For patients unfit for oesophagectomy but at high risk of cancer progression: consider radiotherapy (alone or with chemotherapy) 1
• For low-risk T1b EAC (invasion depth ≤500 μm, no lymphovascular invasion, no poor tumor differentiation): consider endoscopic resection with adequate follow-up in expert centers 3

Post-Treatment Follow-up

After Endoscopic Eradication Therapy

• First endoscopic follow-up should be performed in an expert center 3
• Carefully inspect the neo-squamocolumnar junction and neo-squamous epithelium with high-definition white-light endoscopy and virtual chromoendoscopy 3
• Obtain biopsies just distal to a normal-appearing neo-squamocolumnar junction 3
• For patients with baseline HGD or EAC: follow-up at 1,2,3,4,5,7, and 10 years after last treatment 3
• For patients with baseline LGD: follow-up at 1,3, and 5 years after last treatment 3

Important Considerations and Pitfalls

• Do not offer aspirin to prevent progression to oesophageal dysplasia and cancer 1
• The risk of progression from non-dysplastic Barrett's esophagus to esophageal adenocarcinoma is less than 0.5% per year, but regular surveillance is still recommended 4
• Ensure that dysplasia diagnosis is confirmed by at least two expert gastrointestinal pathologists to avoid unnecessary interventions 1
• For staging suspected T1b oesophageal adenocarcinoma, consider EUS for nodal staging 1
• Do not use CT before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma 1