Ablation Therapy for Barrett’s Esophagus: New Rules for Changing Times

Abstract

Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.

Recent advances in Barrett's esophagus

“…The APE study evaluated the efficacy of APC versus surveillance for patients who had undergone EMR for neoplastic BE. The study showed a decrease in residual (secondary) lesions with APC (3% versus 36%) and the need for secondary therapy . The hybrid APC technique (submucosal injection of saline prior to thermal ablation) also showed promising results in a study by Manner et al .…”

“…EMR is the treatment of choice for nodular disease, short segment disease, and focal lesions in long‐segment BE. Multiple studies have demonstrated that complete eradication of intestinal metaplasia (CE‐IM) is high (80–85%) . However, the long‐term recurrence rate varies from 16% to 39% for CE‐IM and 6% for recurrence after achieving complete eradication of neoplasia (CE‐N) respectively.…”

“…Multiple studies have demonstrated that complete eradication of intestinal metaplasia (CE-IM) is high (80-85%). [66][67][68] However, the longterm recurrence rate varies from 16% to 39% for CE-IM and 6% for recurrence after achieving complete eradication of neoplasia (CE-N) respectively. The major complication is stricture formation that occurs in 37% of patients.…”

“…The study showed a decrease in residual (secondary) lesions with APC (3% versus 36%) and the need for secondary therapy. 68,76 The hybrid APC technique (submucosal injection of saline prior to thermal ablation) also showed promising results in a study by Manner et al with 78% histologic remission. 77 The rate of esophageal strictures was reported to be 4-9% and 2% in the APC and hybrid APC arms, respectively.…”

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

“…15,16 There is insufficient evidence to support eradication of IM in the absence of dysplasia. 47 Complete eradication of IM can be achieved in various ways. In Western nations the mucosal lesion or dysplastic area is usually found within a significantly long segment of BE rather than in a short segment that is amenable to a onestep approach of therapy.…”