Barrett's esophagus endoscopic therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Manpreet Kaur, MD [2] Amresh Kumar MD [3]
Overview
Endoscopic Therapy
Endoscopic therapy is classified into two types:[1][2]
- Tissue acquiring therapies are:
- Endoscopic mucosal resection
- Endoscopic submucosal dissection
- Non-tissue acquiring or ablative therapies are:
- Radiofrequency ablation
- Photodynamic therapy
- Cryotherapy
- Argon plasma coagulation
Clinical practice guidelines
According to the American College of Gastroenterology, indication for the endoscopic therapy in Barrett's esophagus patients are:[3][4]
- Patients with nodularity in Barrett’s esophagus segment should undergo endoscopic mucosal resection (EMR) of the nodular lesion(s) as the initial diagnostic and therapeutic maneuver. Histologic assessment of the endoscopic mucosal resection specimen should guide further therapy. In subjects with endoscopic mucosal resection specimens demonstrating high-grade dysplasia or intramucosal carcinoma, endoscopic ablative therapy of the remaining Barrett's esophagus should be performed.
- In patients with endoscopic mucosal resection specimens demonstrating neoplasia at a deep margin, residual neoplasia should be assumed, and surgical, systemic, or additional endoscopic therapies should be considered.
- Endoscopic ablative therapies should not be routinely applied to patients with nondysplastic Barrett's esophagus because of their low risk of progression to esophageal adenocarcinoma. Endoscopic eradication therapy is the procedure of choice for patients with confirmed low-grade dysplasia and confirmed high-grade dysplasia
- In patients with T1a esophageal adenocarcinoma, endoscopic therapy is the preferred therapeutic approach, being both effective and well tolerated.
- In patients with T1b esophageal adenocarcinoma, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy. In such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates.
- Routine staging of patients with nodular Barrett's esophagus with endoscopic ultrasound or other imaging modalities before EMR has no demonstrated benefit. Given the possibility of over- and understanding, findings of these modalities should not preclude the performance of endoscopic mucosal resection to stage-early neoplasia.
- In patients with the known T1b disease, Endoscopic ultrasound may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with the less advanced disease.
- In patients with dysplastic Barrett's esophagus who are to undergo endoscopic ablative therapy for the nonnodular disease, radiofrequency ablation is currently the preferred endoscopic ablative therapy.
Trails
Among patients with low-grade dysplasia, radiofrequency ablation reduced progression to high grade dysplasia.[5]
References
- ↑ Pophali P, Halland M (2016). "Barrett's oesophagus: diagnosis and management". BMJ. 353: i2373. doi:10.1136/bmj.i2373. PMID 27169585.
- ↑ Menon D, Stafinski T, Wu H, Lau D, Wong C (2010). "Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy". BMC Gastroenterol. 10: 111. doi:10.1186/1471-230X-10-111. PMC 2955687. PMID 20875123.
- ↑ Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology (2016). "ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus". Am J Gastroenterol. 111 (1): 30–50, quiz 51. doi:10.1038/ajg.2015.322. PMID 26526079.
- ↑ Amano Y, Kinoshita Y (2008). "Barrett esophagus: perspectives on its diagnosis and management in asian populations". Gastroenterol Hepatol (N Y). 4 (1): 45–53. PMC 3394474. PMID 22798736.
- ↑ Phoa KN, van Vilsteren FG, Weusten BL, Bisschops R, Schoon EJ, Ragunath K et al. (2014) Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial. JAMA 311 (12):1209-17. DOI:10.1001/jama.2014.2511 PMID: 24668102