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]

Endoscopic Therapy

According to the American College of Gastroenterology, indication for the endoscopic therapy in Barrett's esophagus patients are:

• Patients with modularity in Barrett’s esophagus segment should undergo endoscopic mucosal resection 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.

Endoscopic therapy is classified into two types:

• 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

Management of nodular Barrett’s esophagus: The identification of mucosal irregularities including nodularity, ulceration, or flat but irregular mucosal contour is essential to detect the areas of highest yield for neoplasia.

Endoscopically visible nodularity in Barrett’s esophagus

Endoscopic mucosal resection

Low grade dysplasia

High grade dysplasia

T1a EAC

T1bEAC

D01' D01

D02' D02

E01

E02

E03

E04

F01

F02

F03

Several endoscopic therapies are available to treat severe dysplasia and cancer. During these therapies, the Barrett’s lining is destroyed or the portion of the lining that has dysplasia or cancer is cut out. The goal of the treatment is to encourage normal esophageal tissue to replace the destroyed Barrett’s lining. Endoscopic therapies are performed at specialty centers by physicians with expertise in these procedures.

• Photodynamic therapy (PDT) : PDT uses a light-sensitizing agent called Photofrin and a laser to kill precancerous and cancerous cells. Photofrin is injected into a vein and the patient returns 48 hours later. The laser light is then passed through the endoscope and activates the Photofrin to destroy Barrett’s tissue in the esophagus. Complications of PDT include chest pain, nausea, sun sensitivity for several weeks, and esophageal strictures.
• Endoscopic mucosal resection (EMR): EMR involves lifting the Barrett’s lining and injecting a solution under it or applying suction to it and then cutting it off. The lining is then removed through the endoscope. If EMR is used to treat cancer, an endoscopic ultrasound is done first to make sure the cancer involves only the top layer of esophageal cells. The ultrasound uses sound waves that bounce off the walls of the esophagus to create a picture on a monitor. Complications of EMR can include bleeding or tearing of the esophagus. EMR is sometimes used in combination with PDT.