From the Guidelines
Barrett's esophagus treatment should prioritize endoscopic resection of visible oesophageal lesions as first-line treatment for people with high-grade dysplasia, followed by endoscopic ablation of any residual Barrett's oesophagus. This approach is supported by the most recent and highest quality study, the 2024 National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma 1. The guidance recommends endoscopic resection of visible lesions as the primary treatment for high-grade dysplasia, and subsequent ablation of any remaining Barrett's oesophagus tissue.
Key Recommendations
- For patients with high-grade dysplasia, endoscopic resection of visible oesophageal lesions should be the first-line treatment, followed by endoscopic ablation of any residual Barrett's oesophagus 1.
- For patients with low-grade dysplasia, radiofrequency ablation should be offered, with confirmation of the histological diagnosis by two gastrointestinal pathologists 1.
- For patients with indefinite dysplasia, endoscopic surveillance at 6 monthly intervals with dose optimisation of acid-suppressant medication should be considered 1.
- Endoscopic follow-up should be offered to people who have received endoscopic treatment for Barrett's oesophagus with dysplasia 1.
Rationale
The NICE guidance is based on the latest evidence and provides a clear framework for managing Barrett's oesophagus with dysplasia. The recommendations prioritize endoscopic resection and ablation for high-grade dysplasia, and radiofrequency ablation for low-grade dysplasia. These approaches aim to eliminate the abnormal tissue and reduce the risk of progression to esophageal adenocarcinoma. The guidance also emphasizes the importance of regular endoscopic surveillance and dose optimization of acid-suppressant medication for patients with indefinite dysplasia.
Comparison with Other Evidence
While the 2011 American Gastroenterological Association (AGA) medical position statement on the management of Barrett's esophagus provides some guidance on endoscopic eradication therapy, it is outdated compared to the 2024 NICE guidance 1. The AGA statement recommends shared decision-making between the physician and patient, but does not provide clear recommendations on the primary treatment for high-grade dysplasia. In contrast, the NICE guidance provides a clear and evidence-based approach to managing Barrett's oesophagus with dysplasia. Therefore, the NICE guidance should be prioritized in clinical practice.
From the Research
Treatment Options for Barrett's Esophagus
- Endoscopic surveillance is a recommended treatment approach for patients with Barrett's esophagus, with the goal of detecting dysplasia and preventing the progression to invasive malignancy 2, 3, 4.
- The American College of Gastroenterology recommends the following practice guidelines:
- For patients with no dysplasia, surveillance endoscopy is recommended at an interval of every 2 to 3 years 2.
- For patients with low-grade dysplasia, surveillance endoscopy every 6 months for the first year is recommended, followed by yearly endoscopy if the dysplasia has not progressed in severity 2.
- For patients with high-grade dysplasia, intensive endoscopic surveillance until intramucosal cancer is detected at an interval of every 3-6 months, or esophageal resection, are proposed alternatives 2.
- Endoscopic ablative therapy is recommended for patients with Barrett's esophagus and high-grade dysplasia, as well as T1a esophageal adenocarcinoma 3, 5.
- Endoscopic eradication therapy is also recommended for patients with Barrett's esophagus and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative 3, 5.
Surveillance Intervals
- The recommended surveillance intervals for patients with Barrett's esophagus vary depending on the degree of dysplasia:
Other Considerations
- Patients with long-segment Barrett's esophagus need endoscopic surveillance, even if they underwent antireflux surgery 4.
- The use of biomarker panels or advanced endoscopic imaging techniques is not recommended at this time 3.
- Proton pump inhibitors can be used to help control reflux symptoms, but there is no evidence that medical or surgical therapies to reduce acid reflux prevent neoplastic progression 6.