Treatment of Barrett's Esophagus
The treatment of Barrett's esophagus depends critically on the presence and grade of dysplasia: non-dysplastic Barrett's requires only medical therapy with PPIs and surveillance endoscopy every 3-5 years, while dysplastic Barrett's mandates endoscopic eradication therapy with radiofrequency ablation (RFA) to prevent progression to esophageal adenocarcinoma. 1, 2
Medical Management for Non-Dysplastic Barrett's Esophagus
Proton pump inhibitors (PPIs) are the cornerstone of medical therapy and should be used primarily for symptom control of gastroesophageal reflux disease (GERD), not for cancer prevention. 1 There is insufficient evidence to recommend high-dose PPI therapy solely to prevent progression to dysplasia or cancer. 1, 3
Antireflux surgery should NOT be offered to prevent neoplastic progression of Barrett's esophagus, as it is not superior to medical therapy for this purpose. 1, 3 Surgery should only be considered in patients with poor or partial symptomatic response to PPIs. 1
Surveillance Strategy
All patients with Barrett's esophagus require endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma. 1, 3 The surveillance intervals are stratified by Barrett's segment length:
- For Barrett's < 3 cm: Surveillance every 5 years 2
- For Barrett's ≥ 3 cm and < 10 cm: Surveillance every 3 years 2
- For Barrett's ≥ 10 cm: Refer to a Barrett's expert center 2
Proper biopsy protocol is critical: Obtain 4-quadrant biopsies every 2 cm of Barrett's segment for patients without known dysplasia, and every 1 cm for patients with known dysplasia. 1, 2 Surveillance may be discontinued if the patient reaches 75 years of age or has a life expectancy less than 5 years. 2
Management of Low-Grade Dysplasia (LGD)
Radiofrequency ablation (RFA) should be offered to patients with confirmed low-grade dysplasia diagnosed from biopsy samples taken at two separate endoscopies. 1, 2 The diagnosis must be confirmed by at least two pathologists, preferably one expert in esophageal histopathology, before initiating endoscopic eradication therapy. 4, 1
RFA therapy for low-grade dysplasia leads to reversion to normal-appearing squamous epithelium in 90% of cases. 4 An acceptable alternative in patients with life-limiting comorbidities is endoscopic surveillance every 12 months. 5
Management of High-Grade Dysplasia (HGD)
For high-grade dysplasia without visible lesions, endoscopic ablation treatment is recommended to prevent progression to invasive cancer. 2 RFA therapy reduces progression to esophageal cancer, as demonstrated in randomized sham-controlled trials. 4
For high-grade dysplasia with visible mucosal irregularities, endoscopic resection should be performed first to determine the T stage of the neoplasia, followed by ablation of any residual Barrett's epithelium. 4, 1, 2
RFA appears to have at least comparable efficacy and fewer serious adverse effects compared with photodynamic therapy (PDT). 4 The goal is complete eradication of all Barrett's epithelium, which appears more effective than therapy that removes only localized areas of dysplasia. 4
Management of Early Esophageal Adenocarcinoma
For T1a (intramucosal) esophageal adenocarcinoma: Endoscopic resection should be offered as first-line treatment, followed by ablation of remaining Barrett's epithelium. 1, 2 This approach successfully treats 80-90% of patients. 6
For low-risk T1b (submucosal) esophageal adenocarcinoma (submucosal invasion ≤ 500 µm AND no lymphovascular invasion AND no poor tumor differentiation): Endoscopic resection can be considered, provided adequate follow-up with gastroscopy, endoscopic ultrasound, and CT/PET-CT is performed in expert centers. 2, 5
For high-risk T1b tumors (invasion > 500 µm, lymphovascular invasion, or poor differentiation): Esophagectomy should be offered to patients who are fit for surgery, with consideration of additional chemotherapy and/or radiotherapy in multidisciplinary discussion. 1, 2
Post-Eradication Surveillance
After successful endoscopic eradication therapy, surveillance intervals depend on baseline diagnosis:
For patients with baseline HGD or adenocarcinoma: Surveillance at 1,2,3,4,5,7, and 10 years after last treatment, after which surveillance may be stopped. 2
For patients with baseline LGD: Surveillance at 1,3, and 5 years after last treatment, after which surveillance may be stopped. 2
During post-eradication surveillance, careful inspection of the neo-squamocolumnar junction with high-definition white-light endoscopy and virtual chromoendoscopy is recommended. 2 Routine four-quadrant biopsies of neo-squamous epithelium are NOT recommended, but targeted biopsies should be obtained where there is suspicion of recurrent Barrett's or visible lesions. 2
Common Pitfalls and Caveats
Do not attempt to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for prevention of esophageal adenocarcinoma — this approach is not supported by evidence. 1, 3
Do not use endoscopic ultrasonography (EUS) before endoscopic resection for staging suspected T1a esophageal adenocarcinoma — it is not recommended by current guidelines. 1
Cryotherapy currently lacks adequate evidence: The literature is insufficient to recommend cryotherapy for confirmed dysplasia or to assess its ability to achieve sustained reversion to squamous epithelium. 4
Chemoprevention with aspirin or NSAIDs is not recommended specifically for Barrett's esophagus, though patients should be screened for cardiovascular risk factors for which aspirin might be indicated for other reasons. 1