How should Barrett's esophagus be managed, including treatment for non‑dysplastic disease and for low‑grade or high‑grade dysplasia?

Treatment for Barrett's Esophagus

The treatment of Barrett's esophagus is stratified by dysplasia grade: non-dysplastic disease requires surveillance only with PPI therapy for symptom control; confirmed low-grade dysplasia should be treated with radiofrequency ablation (RFA); and high-grade dysplasia requires endoscopic eradication therapy with RFA and endoscopic mucosal resection (EMR) for visible lesions. 1, 2

Non-Dysplastic Barrett's Esophagus

Medical Management:

• Proton pump inhibitors (PPIs) are the cornerstone of therapy for symptom control of GERD, but should not be used solely for cancer prevention 2, 3
• High-dose PPI therapy is not recommended to prevent progression to dysplasia or cancer 3
• Antireflux surgery should not be offered to prevent neoplastic progression, as it is not superior to medical therapy for this purpose 2, 3
• Surgery should only be considered in patients with poor or partial symptomatic response to PPIs 2, 3

Surveillance Strategy:

• Endoscopic surveillance is required for all patients with Barrett's esophagus 2, 3
• Surveillance intervals depend on Barrett's segment length: every 3-5 years for non-dysplastic disease 3, 4
• Proper biopsy protocol requires 4-quadrant biopsies every 2 cm of Barrett's segment 2, 3
• Minimum 1-minute inspection time per cm of BE length during surveillance 4

Endoscopic eradication therapy is NOT recommended for non-dysplastic Barrett's esophagus in the general population, as there is no evidence it reduces cancer risk or is cost-effective compared to surveillance. 1

Low-Grade Dysplasia (LGD)

Diagnostic Confirmation:

• The diagnosis must be confirmed by at least 2 pathologists, preferably one expert in esophageal histopathology, before initiating any treatment 1, 5
• Repeat high-definition white-light endoscopy within 3-6 months to rule out visible lesions 1
• Any visible lesions must undergo endoscopic resection first to accurately assess the true grade of dysplasia 1, 5

Treatment Options:

• RFA should be offered to patients with confirmed and persistent LGD diagnosed from biopsy samples taken at two separate endoscopies 2, 5, 4
• RFA leads to reversion to normal-appearing squamous epithelium in 90% of cases 1, 2
• Both endoscopic eradication therapy and continued surveillance are reasonable options, requiring shared decision-making between physician and patient 1

Surveillance if Ablation Not Performed:

• Every 6 months for the first year, then annually thereafter 5

High-Grade Dysplasia (HGD)

Endoscopic eradication therapy is the preferred treatment for HGD. 1, 2

Treatment Algorithm:

• For HGD without visible lesions: endoscopic ablation with RFA to prevent progression to invasive cancer 2, 4
• For HGD with visible mucosal irregularities: EMR should be performed first to determine T stage, followed by ablation of residual Barrett's epithelium 1, 2
• RFA reduces progression to esophageal cancer, as demonstrated in randomized sham-controlled trials 1, 2

Role of Esophagectomy:

• Most patients (70-80%) with HGD can be successfully treated with endoscopic eradication therapy 1
• Esophagectomy is an alternative but has greater morbidity compared to ablative therapy 1
• Before proceeding with esophagectomy, patients should be referred to surgical centers specializing in foregut cancers 1

Early Esophageal Adenocarcinoma

T1a (Intramucosal) Disease:

• Endoscopic resection is preferred over esophagectomy 1, 2
• Endoscopic resection should be followed by ablation of remaining Barrett's epithelium 3, 4
• This approach is curative for T1a cancer with well/moderate differentiation and no lymphovascular invasion 4

T1b (Submucosal) Disease:

• Low-risk features (≤500 μm invasion [sm1], good to moderate differentiation, no lymphatic invasion): endoscopic therapy is reasonable, especially in poor surgical candidates 1, 4
• High-risk features (>500 μm invasion, lymphovascular invasion, or poor differentiation): consider additional treatments or surgery in multidisciplinary discussion 4

Technical Aspects of Endoscopic Eradication Therapy

Ablation Technique:

• Mucosal ablation should be applied to: 1) all visible esophageal columnar mucosa; 2) 5-10 mm proximal to the squamocolumnar junction; and 3) 5-10 mm distal to the gastroesophageal junction 1
• Ablation should only be performed on flat BE without inflammation and without visible abnormalities 1
• Complete eradication of all Barrett's epithelium is more effective than focal therapy 1

Center Requirements:

• Endoscopic eradication therapy should be performed by experts in high-volume centers performing minimum 10 new cases annually 1

Post-Ablation Surveillance:

• Continue therapy until complete absence of columnar epithelium on high-definition white-light endoscopy 1
• After complete eradication, perform 4-quadrant biopsies of neosquamous mucosa and gastric cardia 1
• For HGD/EAC: surveillance at 1,2,3,4,5,7, and 10 years after last treatment 4
• For LGD: surveillance at 1,3, and 5 years after last treatment 4

Common Pitfalls and Caveats

Critical Errors to Avoid:

• Do not proceed with ablation based on community pathology alone—always obtain expert GI pathology confirmation 5
• Do not ablate visible lesions—these require endoscopic resection first for accurate histologic staging 1, 5
• Do not perform surveillance biopsies in the presence of severe erosive esophagitis—optimize acid suppression first 5
• Cryotherapy currently lacks adequate evidence for dysplasia treatment and cannot be recommended 1, 2

Chemoprevention:

• Aspirin or NSAIDs are not recommended specifically for Barrett's esophagus prevention 2, 5, 3
• Screen patients for cardiovascular risk factors for which aspirin might be indicated for other reasons 1, 2, 3

Complications:

• The most common complication of endoscopic therapy is post-procedural stricture formation, occurring in approximately 6% of cases 1