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

Management of Barrett's Esophagus

For Barrett's esophagus without dysplasia, provide proton pump inhibitors for symptom control and perform surveillance endoscopy every 3-5 years; for confirmed low-grade dysplasia, offer radiofrequency ablation; for high-grade dysplasia or T1a adenocarcinoma, perform endoscopic resection followed by ablation of residual Barrett's tissue. 1, 2, 3

Initial Assessment and Patient Education

• Offer a clinical consultation immediately after diagnosis to discuss the annual cancer progression risk of approximately 0.2-0.5% and establish a surveillance plan 1, 4, 5
• Provide both verbal and written information about the diagnosis, treatment options, and patient support groups 3, 4
• Ensure patients understand that Barrett's esophagus is a premalignant condition requiring long-term monitoring but has a relatively low cancer risk 5

Symptom Control and Medical Management

• Use proton pump inhibitors as first-line therapy for gastroesophageal reflux symptom control 3, 4, 5
• Do not offer anti-reflux surgery specifically to prevent progression to dysplasia or cancer, as it is not more effective than medical therapy for cancer prevention 1, 3, 4
• Do not prescribe aspirin specifically to prevent progression to esophageal dysplasia and cancer 3, 4

Endoscopic Surveillance Protocol

Technique Standards

• Use high-resolution white light endoscopy with the Seattle biopsy protocol: four-quadrant biopsies every 2 cm throughout the Barrett's segment 1, 3, 4, 6
• Maintain a minimum of 1-minute inspection time per cm of Barrett's esophagus length during surveillance 6
• Document landmarks, the Barrett's segment (one picture per cm of length), and the esophagogastric junction in retroflexed position 6
• Use the Prague classification for Barrett's length and Paris classification for visible lesions 6

Surveillance Intervals Based on Dysplasia Status

Non-dysplastic Barrett's esophagus:

• Perform surveillance endoscopy every 3-5 years 1, 4, 7
• For Barrett's segments ≥1 cm and <3 cm: surveillance every 5 years 6
• For Barrett's segments ≥3 cm and <10 cm: surveillance every 3 years 6
• For Barrett's segments ≥10 cm: refer to a Barrett's esophagus expert center 6
• For irregular Z-line or columnar-lined esophagus <1 cm: no routine biopsies or surveillance needed 6

Indefinite for dysplasia:

• Perform endoscopic surveillance at 6-month intervals with dose optimization of acid-suppressant medication 1, 3, 4

Low-grade dysplasia:

• Confirm the diagnosis with biopsy samples from two separate endoscopic examinations, verified by at least two expert gastrointestinal pathologists 1, 2, 3, 4
• This confirmation step is critical because low-grade dysplasia is frequently overcalled by community pathologists, particularly when esophageal inflammation is present 2
• Offer radiofrequency ablation as primary treatment once diagnosis is confirmed 1, 2, 3, 4, 6
• For patients who decline or defer ablation: perform surveillance at 6-12 month intervals 2

High-grade dysplasia:

• Offer endoscopic resection of visible esophageal lesions as first-line treatment 1, 3, 4, 6
• Offer endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1, 3, 4, 6
• For high-grade dysplasia without visible lesions: offer endoscopic ablation treatment to prevent progression to invasive cancer 6

When to Discontinue Surveillance

• Consider discontinuing surveillance if the patient has reached 75 years of age at the time of the last surveillance endoscopy and/or life expectancy is less than 5 years 6

Management of Stage 1 Esophageal Adenocarcinoma

T1a Adenocarcinoma

• Offer endoscopic resection as first-line treatment 1, 3, 4, 6
• Endoscopic resection is curative for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion 6
• Offer endoscopic ablation of any residual Barrett's esophagus after endoscopic resection 1, 3, 4, 6
• Offer endoscopic follow-up to monitor for recurrence 1, 3

T1b Adenocarcinoma

• For patients fit for surgery with high-risk features (incomplete endoscopic resection, lymphovascular invasion, or deep submucosal invasion >500 μm): offer oesophagectomy 1, 3, 4
• Low-risk submucosal T1b adenocarcinoma (submucosal invasion ≤500 μm AND no lymphovascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection with adequate follow-up including gastroscopy, endoscopic ultrasound, and CT/PET-CT in expert centers 6
• For patients unfit for oesophagectomy but at high risk of cancer progression: consider radiotherapy alone or combined with chemotherapy 1, 3, 4
• High-risk T1b adenocarcinoma (invasion >500 μm, lymphovascular invasion, or poor differentiation) requires complete staging and multidisciplinary discussion for additional treatments 6
• Offer endoscopic follow-up after radiotherapy 1

Staging Considerations

• Do not use CT before endoscopic resection for staging suspected T1 oesophageal adenocarcinoma 3, 4
• Do not use endoscopic ultrasonography before endoscopic resection for staging suspected T1a oesophageal adenocarcinoma 1, 4
• Consider endoscopic ultrasound for nodal staging in patients with suspected T1b oesophageal adenocarcinoma based on endoscopic appearances or histological examination 1, 3, 4

Post-Eradication Therapy Surveillance

First Follow-up

• Perform the first endoscopic follow-up after successful endoscopic eradication therapy in an expert center 6
• Use high-definition white-light endoscopy and virtual chromoendoscopy to carefully inspect the neo-squamocolumnar junction and neo-squamous epithelium for recurrent dysplasia 6

Biopsy Protocol After Eradication

• Do not perform routine four-quadrant biopsies of neo-squamous epithelium after successful endoscopic eradication therapy 6
• Obtain four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions 6
• Obtain targeted biopsies where there is suspicion of recurrent Barrett's esophagus in the tubular esophagus or visible lesions suspicious for dysplasia 6

Surveillance Intervals After Successful Eradication

For baseline diagnosis of high-grade dysplasia or adenocarcinoma:

• Surveillance at 1,2,3,4,5,7, and 10 years after last treatment, after which surveillance may be stopped 6

For baseline diagnosis of low-grade dysplasia:

• Surveillance at 1,3, and 5 years after last treatment, after which surveillance may be stopped 6

Critical Pitfalls to Avoid

• Never proceed with ablation based on a single pathologist's diagnosis or single endoscopy for low-grade dysplasia, as the false-positive rate is extremely high in community practice 2
• Do not offer anti-reflux surgery or aspirin specifically for cancer prevention, as evidence does not support these interventions 1, 2, 3, 4
• Ensure all dysplasia diagnoses are confirmed by at least two expert gastrointestinal pathologists to avoid unnecessary interventions 2, 4
• Optimize acid suppression before repeat biopsies in cases of indefinite dysplasia to minimize inflammation that can confound dysplasia diagnosis 2