Surgery for Acid Suppression 

• Appropriate surgical candidates may consider fundoplication to control reflux symptoms
• Surgical intervention to prevent adenocarcinoma remains unproven

Endoscopic Therapy

• Goals of therapy include eradication of dysplasia and/or cancer, prevention of progression to invasive cancer and reduction of mortality from esophageal adenocarcinoma 
• Visible lesions are resected then the mucosa is ablated to achieve complete eradication of intestinal metaplasia 
  • Eliminates Barrett's epithelium by removing the tissue (eg endoscopic mucosal resection or endoscopic submucosal dissection) and/or ablating the tissue (eg radiofrequency ablation, hybrid argon plasma coagulation or cryotherapy) 
  • Mucosal ablation should only be done with flat Barrett's esophagus without inflammation and visible abnormalities 
• Most common complications include formation of stricture, bleeding and perforation 
• Recurrent disease is treated similarly as that of the initial disease 
• Counsel patients regarding cancer risk in the absence of or after endoscopic therapy

Low-Grade Dysplasia

• If endoscopy shows a visible focal lesion, complete resection of the lesion should be performed; if focal lesions are absent, may consider radiofrequency ablation 
• Patients with documented and persistent low-grade dysplasia may be managed with both endoscopic therapy and continued surveillance 

High-Grade Dysplasia

• Preferred treatment over esophagectomy 
• For patients with confirmed multifocal high-grade dysplasia, intervention should be considered (eg endoscopic mucosal resection, radiofrequency ablation or ablation using cryotherapy, photodynamic therapy, esophagectomy)
  • Complete endoscopic and histologic eradication of the Barrett’s esophagus segment along with other dysplastic lesions is the goal of endoscopic treatment in patients with Barrett’s esophagus-associated neoplasia 
  • Any visible raised or suspicious lesions should undergo diagnostic endoscopic resection in patients with dysplastic Barrett’s esophagus or early esophageal adenocarcinoma 
  • Radiofrequency ablation is the preferred endoscopic ablative therapy for patients with flat-type dysplastic Barrett’s esophagus non-nodular disease; undetected synchronous lesions can be treated and development of metachronous lesions can be prevented 
    • Mucosal ablation should be applied circumferentially using focal/targeted therapy to the GEJ/gastric cardia as this is an area that is difficult to treat and a common site for recurrent neoplasia 
• As synchronous cancer can occur with high-grade dysplasia, intervention (eg endoscopic resection) instead of continued surveillance may be done 
  • Endoscopic resection may be performed if the lesion can be localized endoscopically

Esophagectomy 

• Some clinicians recommend esophagectomy for healthy patients with high-grade dysplasia or patients with invasion of the submucosa, lymph node metastasis or failed endoscopic therapy
• The natural history of high-grade dysplasia is variable and therefore, the decision to perform esophagectomy should be carefully considered
• Associated with higher morbidity and mortality at low-volume institutions
• Esophagectomy at a high-volume institution may be considered in patients who are fit for surgery with recurrent, diffuse, high-grade dysplasia that is confirmed by an expert/experienced gastrointestinal pathologist